The quality movement has spawned efforts to define and measure best practices for clinical conditions commonly cared for by hospitalists. Pneumonia is the most frequent infectious cause of death in the United States, and it accounts for more than 1 million hospitalizations annually at an estimated annual cost of $12.2 billion, most of it incurred by inpatients.1 The morbidity and mortality of the elderly are particularly burdensome.2, 3 For these reasons, attention has been focused on improving the quality of care of inpatients with community‐acquired pneumonia (CAP).

Credentialing agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require hospitals to report performance on predefined core measures of pneumonia care that they have identified as best practices (see Table 1).4, 5 The performance of individual organizations on these measures is now publicly reported at a website (www.hospitalcompare.hhs.gov) sponsored by the U.S. Department of Health and Human Services in conjunction with the Hospital Quality Alliance. Similar information is available at JCAHO's www.qualitycheck.org. Health care consumers can review quality data from the institution of their choice and compare the performance of various hospitals. The Centers for Medicare & Medicaid Services (CMS) provides financial incentives for the public reporting of such data and distributed $8.85 million to the top‐performing hospitals participating in a demonstration project in 2005.68 Voluntary reporting of performance on quality measures by individual physicians,9 as well as hospitals, is now being encouraged. As congress currently considers implementing pay for performance measures as a means to improve physician reimbursement, reporting will ultimately be linked to physician payments.

Performance on core measures for pneumonia is less consistent across hospitals than the other conditions currently being monitored.7 It is instructive, then, to review the evidence base for the existing pneumonia quality measures, which can inform decisions about prioritizing interventions to provide the most effective care for inpatients with CAP.

BLOOD CULTURES

In a large multicenter retrospective study of Medicare patients hospitalized with CAP, Meehan et al.10 found the performance of blood cultures within 24 hours of arrival to be associated with reduced 30‐day mortality. Despite the large sample size of more than 14,000 patients, the risk‐adjusted mortality reduction was of only borderline significance (RR 0.9 [0.81‐1.00]). The unadjusted data did not show a significant mortality reduction. Notably, collection of blood cultures prior to antibiotic administration did not affect mortality, even excluding patients receiving prehospital antibiotics.

A smaller review of 38 U.S. academic medical centers showed relatively high compliance with blood culture performance, but no mortality reduction, even after adjustment for severity of illness. Similarly, performing blood cultures before administration of antibiotics yielded no significant effect.11

Several studies call into question the clinical utility of performing blood cultures drawn from patients with CAP. Combined, these studies evaluated almost 3000 pneumonia patients who had blood cultures drawn; the likelihood of a change in therapy based on results was at most 5%. Among the patients with positive cultures, only 20%‐40% had a treatment change based on the result.1215

The more severely ill patients with CAP may benefit from blood cultures, though the findings reported in the literature vary.12, 16 Using the Pneumonia Severity Index (PSI) score17 to classify severity of illness, an observational study of 209 inpatients with CAP found the yield of blood cultures increased from 10% in the lowest‐risk groups to 27% in the most severely ill.16 In contrast, two larger studies with a combined enrollment of almost 14,000 patients were unable to demonstrate a difference in the incidence of bacteremia despite adjustment for the PSI score.12, 18 It is clear from these and other studies that patients in PSI classes I‐III derive very little benefit from the performance of blood cultures.12, 16, 19

Metersky et al.18 described a prospectively validated risk assessment tool that reliably predicted bacteremia in Medicare patients with CAP and explored its utility in reducing unnecessary blood cultures. Independent risk factors for bacteremia included prior antibiotic use, liver disease, hypotension, tachycardia, fever or hypothermia, BUN > 30 mg/dL, sodium < 130 mmol/L, and WBC < 5000 or > 20,000/mm². Use of this tool predicted bacteremia in 89% of patients and avoided 39% of unnecessary blood cultures. The authors also tested a modified version of the tool that excluded the laboratory abnormalities, so rapid assessment could be made at the initial patient presentation. This version advocated a single blood culture for most patients, and 2 blood cultures for patients with 2 or more risk factors. The modified tool accurately identified 88% of the patients with bacteremia and enabled a 44% reduction in unnecessary cultures.

In summary, blood cultures occasionally provide useful clinical information about etiology and resistance patterns, but they do not seem to reliably influence therapeutic decisions. It seems inappropriate to recommend against their use in practice, but they are not a solid benchmark for evidence‐based quality care. Measures that mandate risk assessment of all inpatients with CAP and require blood cultures only for older patients or those judged at high risk by PSI may better reflect quality. Alternatively, performing blood cultures on patients deemed to be high risk by the model of Metersky et al.18 may suffice.

ANTIBIOTIC TIMING

In a study of Medicare patients by Meehan et al.,10 the 30‐day mortality rate was reduced by 15% in the subset of patients who received antibiotics within 8 hours of arrival at the hospital. However, a trend toward mortality reduction was noted for those receiving antibiotics as early as 6 hours after arrival. Rapid administration of antibiotics was thus deemed an important measure of the quality of care of patients with CAP.

Additional studies attempted to confirm this observation. Battleman et al.20 evaluated 700 patients admitted for CAP through the emergency department. They found that a delay of more than 8 hours in the administration of antibiotics was correlated with a prolonged inpatient stay. Mortality rates were not reported. Achieving rapid delivery of antibiotics was closely linked to administration of the first dose of antibiotics in the emergency department.

Conversely, a large retrospective review by Dedier et al.11 found no reduction in inpatient mortality or in length of stay based on rapid antibiotic delivery, despite adjustment for severity of illness. They did not evaluate 30‐day mortality.

The effect of antibiotic timing on the time to clinical stability has also been investigated. Clinical stability was defined as 24 hours of a systolic blood pressure 90 mm Hg, heart rate 100 beats/min, respiratory rate 24 breaths/min, temperature 38.3C (101F), room air oxygen saturation 90%, and the ability to eat. Silber et al.,21 in a review of the records of 409 inpatients with moderate to severe CAP by PSI score, compared patients receiving antibiotics less than 4 hours, between 4 and 8 hours, and more than 8 hours after hospital admission. There was no difference between groups in time to clinical stability, even with adjustment for PSI.

Marrie and Wu22 attempted to define the factors that influenced inpatient mortality of patients with CAP not admitted to the intensive care unit (ICU). In a prospective study of 3043 patients evaluating a clinical pathway, a multivariate analysis showed antibiotic administration within 4 hours was not correlated with reduced mortality.

Although most studies supporting rapid antibiotic delivery used a target of 8 hours, administration in less than 4 hours is the consensus standard for pneumonia care set by CMS and JCAHO.23, 24

A benefit of timing antibiotic administration less than 4 hours after admission has been confirmed by a single, very large retrospective study of Medicare patients at least 65 years old.25 Analysis of a random sample of more than 18,000 patients with CAP who had not received prehospital antibiotics showed that the relative risk reduction for inpatient mortality was 15% in the group receiving antibiotics within 4 hours. Thirty‐day mortality was similarly reduced, and benefits continued for every hour of early antibiotic administration up to 9 hours.

The absolute risk reduction was small, however (0.6%), yielding a number needed to treat of 167 patients to prevent 1 death.

Randomized controlled trials, which would more definitively address the issue of antibiotic timing, are unlikely, as intentionally delaying administration of antibiotics to patients with known CAP is unethical. Hence, reliance on observational data must suffice. Intuitively, it makes sense to begin treatment of a bacterial infection at the earliest time possible. However, it is also known that not all patients present in a typical fashion, and diagnosis is uncertain at least 20% of the time.26 Anecdotal reports suggest that incentivizing physicians on performance measures encourages premature administration of empiric antibiotics to all patients presenting with cough, prior to confirmation of pneumonia.27, 28 Such practices promote further antibiotic resistance, arguably a larger health issue than delay in antibiotic delivery.29, 30

Houck31 offers potential solutions to this problem, such as eliminating the pressure on hospitals to perform at 100% on this measure by reporting performance within acceptable ranges (eg, 70%‐84% and 85%‐100%) Targeting a benchmark of 80% or a duration of 6 hours may also be appropriate. Finally, a 4‐hour benchmark has not been shown to benefit younger patients, so it is important to apply this target only to patients more than 65 years of age.

CHOICE OF ANTIBIOTIC

A retrospective review of 12,945 cases of inpatients with CAP found that, in comparison to ceftriaxone alone, initial antibiotic regimens consisting either of a second‐ or third‐generation cephalosporin plus a macrolide or of a fluoroquinolone alone were associated with an approximately 30% reduction in 30‐day mortality.32 Hence, current guidelines recommend the combination of a B‐lactam and macrolide, a B‐lactam and doxycycline, or a respiratory fluoroquinolone for inpatients with CAP not admitted to the ICU.3335

The results of subsequent studies supported the contention that guideline‐compliant antibiotics improve outcomes. A prospective multicenter study of a clinical pathway that encouraged use of either levofloxacin or cefuroxime plus azithromycin for the initial treatment of inpatient CAP showed significantly reduced mortality. Compared with any other antibiotic regimen, the odds ratio for death was 0.22 with the cephalosporin/macrolide combination and 0.43 with the fluoroquinolone. Of note, early mortality (within 5 days of admission) was not reduced by antibiotic choice.22 Similar results were found in a retrospective analysis, which found the odds of 30‐day mortality increased by 5.7 in patients not receiving guideline‐compliant therapy.36 A third study found guideline‐compliant antibiotics reduced the likelihood of a prolonged length of stay by 45%.20

Of note, data on the effectiveness of the cephalosporin/doxycycline combination are limited, and the major guidelines differ about whether this regimen is appropriate for inpatients with CAP.33, 34 Important findings from a recent retrospective cohort study showed that initial therapy with ceftriaxone plus doxycycline was associated with reduced inpatient mortality (OR = 0.26) as well as reduced 30‐day mortality (OR = 0.37) compared with other guideline‐compliant therapies for CAP.37 When patients who would not have been considered appropriate for initial doxycycline therapy (those resident in nursing homes, with aspiration pneumonia, or in the ICU) were excluded, a large reduction in inpatient mortality remained (OR = 0.17), without any increase in length of stay or readmission rate. Interestingly, this study suggests the potential superiority of this regimen, though a randomized controlled trial is needed to confirm this. The current core measures do include doxycycline as an acceptable option for CAP therapy (see Table 1).

Currently, controversy remains about whether the benefit of these selected regimens results from their activity against atypical pathogens (Mycoplasma, Legionella, Chlamydia) and whether there is additional benefit from using combination antibiotic therapy.38, 39 Waterer40 described 225 inpatients with bacteremic pneumococcal pneumonia, noting the antibiotic regimen received during the first 24 hours of hospitalization. Patients were classified retrospectively into 3 groupssingle effective therapy (SET), dual effective therapy (DET), or more than dual effective therapy (MET)on the basis of the concordance of pneumococcal sensitivity with the initial antibiotics. Patients on 2 antibiotics were classified in the DET group if the organism was sensitive to both and in the SET group if the organism was resistant to 1 of the 2. Those in the MET group were analyzed separately, as they were found to have a higher baseline severity of illness based on the PSI score; the SET and DET groups were equivalent.

Surprisingly, the SET group was found to have a 3‐fold increase in inpatient mortality; adjustment for severity of illness increased the odds ratio for death to 6.4. Of note, all deaths were in the most severely ill patients (PSI IV‐V). The protective effects of receiving DET were not specifically limited to those receiving a macrolide as the second agent, and multivariate analysis did not find coverage of atypical organisms to be an independent predictor of mortality.

A recent prospective multicenter trial of 844 patients with bacteremic pneumococcal pneumonia at 21 hospitals confirmed these findings.41 A significant 14‐day survival advantage (23% versus 55%) was found in the subgroup of critically ill patients who received at least 2 effective antibiotics. Though survival benefit was restricted to the sickest patients, severity of illness was similar among the groups.

The specific importance of macrolides in combination therapy remains under investigation. A review of a database of inpatients with bacteremic pneumococcal pneumonia over a 10‐year period found that 58% received initial empiric therapy with a B‐lactam/macrolide combination and 42% received B‐lactam without a macrolide (though other antibiotic combinations were not excluded).42 After logistic regression analysis, the investigators found a relative reduction in inpatient mortality of 60% in the patients receiving combination therapy with macrolides. Unfortunately, neither comparison to fluoroquinolone monotherapy nor risk stratification by PSI was reported. A similar study from Canada that did stratify for risk confirmed a mortality benefit of combination therapy.43

A subsequent, extremely large study of more than 44,000 patients from a hospital claims‐made database lent support to these findings.44 This study included all CAP patients regardless of microbiology and was not restricted to those with bacteremia. Outcomes among groups receiving monotherapy with any of the standard agents for CAP were compared with those in groups receiving combination therapy with a macrolide as the second agent. Statistically significant reductions in 30‐day mortality were observed in all groups receiving dual therapy with macrolides. Consistent with other studies, the benefit applied only to patients with more severe CAP. The percentage of patients with bacteremia was not specified.

Of note, this study did not allow direct comparison of fluoroquinolone monotherapy to combination therapy with a B‐lactam and a macrolide. However, the fluoroquinolone/macrolide combination conferred no additional benefit beyond fluoroquinolone monotherapy when adjusted for severity of illness or age. This implies that fluoroquinolone monotherapy is adequate, at least in some subpopulations. This is consistent with initial studies that established the superiority of the antibiotic combinations recommended by the guidelines.20, 22, 32

The potential benefit of combination therapy appears limited to patients with higher severity of illness and pneumococcal bacteremia. However, outcomes are affected by the antibiotic regimen selected in the initial 24‐48 hours of hospitalization, before results of blood cultures are routinely available. At present, clinical prediction of patients who will benefit from combination therapy is difficult.

Coverage of undiagnosed mixed infections with atypical organisms is probably not a major factor benefiting patients receiving combination therapy. Several recent meta‐analyses found no reduction in mortality or the rate of clinical failure among patients receiving antibiotics covering atypical organisms compared with those for patients whose regimens did not have such coverage.4547 Subgroups of patients with Legionella pneumonia do benefit from antibiotics with targeted activity against atypical organisms, but fewer than 1% of all patients were so identified. Evidence for antibiotic synergy is similarly lacking.48, 49 The immunomodulatory effects of macrolides, which decrease cytokine production and inflammation and subsequently reduce the severity of lung injury and other complications of sepsis, are considered potential factors in the reduction of mortality.50

The definition of severe CAP and the indications for ICU admission remain controversial, evidence for which is reviewed elsewhere.34, 51, 52 Antibiotic recommendations for ICU patients are included in Table 1 for completeness, but a detailed review of the evidence is lacking because current guidelines are based on consensus opinion.34 The use of fluoroquinolone monotherapy in severe CAP is not currently recommended because of limitations of the existing evidence. The majority of quinolone trials have excluded severely ill patients, and approval trials of newer respiratory fluoroquinolones have used levofloxacin as a comparator. Studies comparing fluoroquinolones typically allowed investigators in the B‐lactam arm the option of adding macrolides or tetracycline at their discretion. In addition, such trials have been designed as noniferiority trials.38 Clearly, randomized controlled trials are needed to resolve this issue.

Currently, selecting appropriate antibiotics should follow established guidelines, with consideration of using combination therapy for patients with a higher severity of illness. Emphasis on this measure should be stronger than that on antibiotic timing, as the bulk of the evidence favors significant mortality reduction from following guidelines for antibiotic therapy.

VACCINATION

Guidelines recommend all eligible adults hospitalized with CAP receive pneumococcal vaccination on discharge,3335, 53 though there is no evidence this reduces the incidence of pneumonia or death.54, 55 Retrospective studies have shown reduced incidence of invasive disease (bacteremia and meningitis), but not of other end points.5457 The estimated mortality from pneumococcal bacteremia remain as high as 20%‐30%, with no evidence that this rate has decreased over the last 30 years.5861 Despite this, a recent meta‐analysis from the Cochrane database that included only randomized, controlled trials (75,197 patients in 15 trials) was unable to show significant reductions in all‐cause pneumonia or mortality for vaccinated subjects.62 Cohort studies, evaluated separately in this analysis, showed an efficacy of 53% in reducing the incidence of invasive pneumococcal disease. Given the relatively low incidence of invasive disease in the general population, the number needed to treat was estimated at 20,000, or 4000 if only older patients were considered. A subsequent retrospective cohort study showed no reduction in pneumonia hospitalizations, cases of outpatient pneumonia, or mortality among 45,365 elderly vaccinees.56 Some specific subgroups may benefit, however. Vaccinated patients with chronic lung disease did show a reduction in hospitalization for pneumonia (RR 0.57 [0.38‐0.84]) and in mortality (RR 0.7 [0.56‐0.9]) in a retrospective study of HMO patients older than age 65.63

It is of interest that since the licensure of the pediatric 7‐valent protein‐polysaccharide conjugate vaccine in 2000, the incidence of invasive pneumococcal disease among adults has dropped significantly. Overall reduction in invasive disease in adults more than 50 years old was 11% from 1998 to 2003 (relative risk reduction [RRR] = 28%). This is likely the result of decreased transmission from colonized or infected children and not a coincidental increase in adult pneumococcal vaccination, as the rates of disease caused by the 16 strains unique to the 23‐valent vaccine did not change.64, 65 The overall reduction in the incidence of invasive disease is still superior with the adult vaccine, up to 30% in vaccinated subjects (RRR = 44%).56 Invasive disease caused specifically by penicillin‐nonsusceptible serotypes has dropped by 49% in the elderly since introduction of the vaccine.66 Thus, the combined impact of the 2 vaccines may be significant. It is not yet clear what effect, if any, the 7‐valent vaccine will have on the hospitalization rate or mortality.

In contrast to the results for pneumococcal vaccination, studies of the benefits of influenza vaccination have shown clear and consistent reductions in mortality, respiratory illness, hospitalization, and pneumonia, especially among patients with comorbidities.6771 Cost effectiveness has been demonstrated for all populations,72, 73 and the reduction in mortality among high‐risk patients younger than age 65 has been estimated to be as high as 78%.68 Among the elderly, reduction in mortality of about 50% has been reported, along with 20%‐30% reductions in hospitalizations for pneumonia, influenza, cardiac disease, and stroke.70 Reduced incidence of pneumonia in vaccinated patients has even been documented among elderly patients without specific comorbidities.67 Annual revaccination has the most significant impact on mortality.74

The pneumococcal vaccine remains important in the effort to reduce the severity of and complications from invasive pneumococcal disease in the elderly, but the lack of significant benefits on hard end points such as mortality or hospitalizations makes it a less robust measure of quality pneumonia care. In contrast, influenza vaccination has a much larger impact on outcomes in the population at risk. Emphasis should be shifted from pneumococcal to influenza vaccine in pneumonia performance measures.

OXYGENATION ASSESSMENT

It seems intuitive that oxygenation assessment is important in the initial evaluation of patients with CAP, though there is not direct evidence to support this. The recommendation for oxygenation assessment in the published guidelines for CAP is by consensus.3335 Documented hypoxemia is associated with increased pneumonia‐related mortality,17, 75 and clinical judgment does not adequately predict hypoxemia.76 Though the assessment of oxygenation has been found to vary widely among practitioners,77 performance has remained consistent since the advent of monitoring and reporting of quality measures, with compliance rates of 99%.4, 7 Monitoring performance of this measure should continue, though high compliance rates limit its ability to discriminate among institutions.

SMOKING CESSATION COUNSELING

Counseling patients to stop smoking was found to be modestly (2%) but statistically significantly effective in promoting abstinence at 1 year.78 In its report on treating tobacco use, the U.S. Public Health Services recommended that all smokers receive hospital‐ and system‐based interventions at every visit.79 As part of the Pneumonia Patient Outcomes Research Team (PORT) study, smokers with pneumonia underwent a tobacco cessation interview. Though only 15% of these patients quit smoking, 93% of those who quit did so at the time they developed CAP.80 A retrospective study of patients with bacteremic pneumococcal pneumonia found tobacco exposure, including passive smoking, to be a strong independent risk factor for invasive disease.81 The most recent CAP guidelines from the Infectious Disease Society of America (IDSA) recommend smoking cessation counseling for all hospitalized patients who smoke.33 However, hospitals are not likely to have the impact that a more comprehensive, outpatient‐based smoking cessation program would. Without ongoing support, counseling, and pharmacotherapy, the effects of an intervention would be expected to be small.79 Though evidence of benefit is limited, smoking cessation interventions should be encouraged at all sites of care. Quality care merits this regardless of admitting diagnosis, but benefits specific to CAP outcomes have not yet been demonstrated.

CONCLUSIONS

The burden of illness caused by CAP mandates that clinicians strive to deliver the highest quality of care to afflicted patients. Critical evaluation of the strength of the evidence will continue to guide such endeavors, and changes in practice will follow as new information surfaces. Standards of care, as adopted by consensus groups such as the IDSA and American Thoracic Society, will continue to inform the practice of hospitalists.

How quality is defined for public reporting requires particularly careful assessment. The definition of quality should be based on evidence more rigorous than that ascribed to consensus guidelines. Within the profession, guidelines offer reasonable standards of care and delineate areas for further research and are invaluable tools for practicing clinicians. In the public arena, however, proclaiming practices as good or bad sets expectations of health care consumers not educated in the nuances of evaluating clinical evidence and can unfairly bias them against conscientious and effective providers whose standards reflect different interpretations of controversial issues. Regulatory agencies should publicly target interventions using only the most solid evidentiary foundation while internally striving to monitor the effects of different practice patterns and report measurable differences in outcomes revealed by careful investigation. Areas where controversy remains should be the primary targets of further research but should not be offered as benchmarks for public scrutiny until the medical community has settled on a position.

Furthermore, when evidence remains questionable, financial incentives should be linked to performance indicators with extreme caution. It would be counterproductive if health care organizations, driven to achieve optimal antibiotic timing to obtain payment updates from CMS, began to administer antibiotics prior to completing workups on all patients with respiratory complaints, as this would likely lead to antibiotic overuse. Similarly, institutions pushed to collect blood cultures before antibiotics are given may inappropriately delay administration in order to perform well on quality measures, resulting in potential harm to patients.

The measures of quality care for CAP for which the evidence on outcomes is the most convincing are antibiotic selection (mortality benefit, reduction in LOS) and influenza vaccination (mortality benefit, reduction in hospitalizations, reduction in respiratory illness). Antibiotic timing also shows a smaller but convincing reduction in mortality, though the advantages of receiving antibiotics within 4 hours instead of 8 hours are not clearly established for younger patients. These measures should be emphasized most heavily in the arena of public reporting and incentives for quality care, with additions and modifications guided by emerging evidence. Revision of the other measures to conform with current evidence would allow public reporting to more accurately reflect quality.

The quality movement has spawned efforts to define and measure best practices for clinical conditions commonly cared for by hospitalists. Pneumonia is the most frequent infectious cause of death in the United States, and it accounts for more than 1 million hospitalizations annually at an estimated annual cost of $12.2 billion, most of it incurred by inpatients.1 The morbidity and mortality of the elderly are particularly burdensome.2, 3 For these reasons, attention has been focused on improving the quality of care of inpatients with community‐acquired pneumonia (CAP).

Credentialing agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require hospitals to report performance on predefined core measures of pneumonia care that they have identified as best practices (see Table 1).4, 5 The performance of individual organizations on these measures is now publicly reported at a website (www.hospitalcompare.hhs.gov) sponsored by the U.S. Department of Health and Human Services in conjunction with the Hospital Quality Alliance. Similar information is available at JCAHO's www.qualitycheck.org. Health care consumers can review quality data from the institution of their choice and compare the performance of various hospitals. The Centers for Medicare & Medicaid Services (CMS) provides financial incentives for the public reporting of such data and distributed $8.85 million to the top‐performing hospitals participating in a demonstration project in 2005.68 Voluntary reporting of performance on quality measures by individual physicians,9 as well as hospitals, is now being encouraged. As congress currently considers implementing pay for performance measures as a means to improve physician reimbursement, reporting will ultimately be linked to physician payments.

Performance on core measures for pneumonia is less consistent across hospitals than the other conditions currently being monitored.7 It is instructive, then, to review the evidence base for the existing pneumonia quality measures, which can inform decisions about prioritizing interventions to provide the most effective care for inpatients with CAP.

BLOOD CULTURES

In a large multicenter retrospective study of Medicare patients hospitalized with CAP, Meehan et al.10 found the performance of blood cultures within 24 hours of arrival to be associated with reduced 30‐day mortality. Despite the large sample size of more than 14,000 patients, the risk‐adjusted mortality reduction was of only borderline significance (RR 0.9 [0.81‐1.00]). The unadjusted data did not show a significant mortality reduction. Notably, collection of blood cultures prior to antibiotic administration did not affect mortality, even excluding patients receiving prehospital antibiotics.

A smaller review of 38 U.S. academic medical centers showed relatively high compliance with blood culture performance, but no mortality reduction, even after adjustment for severity of illness. Similarly, performing blood cultures before administration of antibiotics yielded no significant effect.11

Several studies call into question the clinical utility of performing blood cultures drawn from patients with CAP. Combined, these studies evaluated almost 3000 pneumonia patients who had blood cultures drawn; the likelihood of a change in therapy based on results was at most 5%. Among the patients with positive cultures, only 20%‐40% had a treatment change based on the result.1215

The more severely ill patients with CAP may benefit from blood cultures, though the findings reported in the literature vary.12, 16 Using the Pneumonia Severity Index (PSI) score17 to classify severity of illness, an observational study of 209 inpatients with CAP found the yield of blood cultures increased from 10% in the lowest‐risk groups to 27% in the most severely ill.16 In contrast, two larger studies with a combined enrollment of almost 14,000 patients were unable to demonstrate a difference in the incidence of bacteremia despite adjustment for the PSI score.12, 18 It is clear from these and other studies that patients in PSI classes I‐III derive very little benefit from the performance of blood cultures.12, 16, 19

Metersky et al.18 described a prospectively validated risk assessment tool that reliably predicted bacteremia in Medicare patients with CAP and explored its utility in reducing unnecessary blood cultures. Independent risk factors for bacteremia included prior antibiotic use, liver disease, hypotension, tachycardia, fever or hypothermia, BUN > 30 mg/dL, sodium < 130 mmol/L, and WBC < 5000 or > 20,000/mm². Use of this tool predicted bacteremia in 89% of patients and avoided 39% of unnecessary blood cultures. The authors also tested a modified version of the tool that excluded the laboratory abnormalities, so rapid assessment could be made at the initial patient presentation. This version advocated a single blood culture for most patients, and 2 blood cultures for patients with 2 or more risk factors. The modified tool accurately identified 88% of the patients with bacteremia and enabled a 44% reduction in unnecessary cultures.

In summary, blood cultures occasionally provide useful clinical information about etiology and resistance patterns, but they do not seem to reliably influence therapeutic decisions. It seems inappropriate to recommend against their use in practice, but they are not a solid benchmark for evidence‐based quality care. Measures that mandate risk assessment of all inpatients with CAP and require blood cultures only for older patients or those judged at high risk by PSI may better reflect quality. Alternatively, performing blood cultures on patients deemed to be high risk by the model of Metersky et al.18 may suffice.

ANTIBIOTIC TIMING

In a study of Medicare patients by Meehan et al.,10 the 30‐day mortality rate was reduced by 15% in the subset of patients who received antibiotics within 8 hours of arrival at the hospital. However, a trend toward mortality reduction was noted for those receiving antibiotics as early as 6 hours after arrival. Rapid administration of antibiotics was thus deemed an important measure of the quality of care of patients with CAP.

Additional studies attempted to confirm this observation. Battleman et al.20 evaluated 700 patients admitted for CAP through the emergency department. They found that a delay of more than 8 hours in the administration of antibiotics was correlated with a prolonged inpatient stay. Mortality rates were not reported. Achieving rapid delivery of antibiotics was closely linked to administration of the first dose of antibiotics in the emergency department.

Conversely, a large retrospective review by Dedier et al.11 found no reduction in inpatient mortality or in length of stay based on rapid antibiotic delivery, despite adjustment for severity of illness. They did not evaluate 30‐day mortality.

The effect of antibiotic timing on the time to clinical stability has also been investigated. Clinical stability was defined as 24 hours of a systolic blood pressure 90 mm Hg, heart rate 100 beats/min, respiratory rate 24 breaths/min, temperature 38.3C (101F), room air oxygen saturation 90%, and the ability to eat. Silber et al.,21 in a review of the records of 409 inpatients with moderate to severe CAP by PSI score, compared patients receiving antibiotics less than 4 hours, between 4 and 8 hours, and more than 8 hours after hospital admission. There was no difference between groups in time to clinical stability, even with adjustment for PSI.

Marrie and Wu22 attempted to define the factors that influenced inpatient mortality of patients with CAP not admitted to the intensive care unit (ICU). In a prospective study of 3043 patients evaluating a clinical pathway, a multivariate analysis showed antibiotic administration within 4 hours was not correlated with reduced mortality.

Although most studies supporting rapid antibiotic delivery used a target of 8 hours, administration in less than 4 hours is the consensus standard for pneumonia care set by CMS and JCAHO.23, 24

A benefit of timing antibiotic administration less than 4 hours after admission has been confirmed by a single, very large retrospective study of Medicare patients at least 65 years old.25 Analysis of a random sample of more than 18,000 patients with CAP who had not received prehospital antibiotics showed that the relative risk reduction for inpatient mortality was 15% in the group receiving antibiotics within 4 hours. Thirty‐day mortality was similarly reduced, and benefits continued for every hour of early antibiotic administration up to 9 hours.

The absolute risk reduction was small, however (0.6%), yielding a number needed to treat of 167 patients to prevent 1 death.

Randomized controlled trials, which would more definitively address the issue of antibiotic timing, are unlikely, as intentionally delaying administration of antibiotics to patients with known CAP is unethical. Hence, reliance on observational data must suffice. Intuitively, it makes sense to begin treatment of a bacterial infection at the earliest time possible. However, it is also known that not all patients present in a typical fashion, and diagnosis is uncertain at least 20% of the time.26 Anecdotal reports suggest that incentivizing physicians on performance measures encourages premature administration of empiric antibiotics to all patients presenting with cough, prior to confirmation of pneumonia.27, 28 Such practices promote further antibiotic resistance, arguably a larger health issue than delay in antibiotic delivery.29, 30

Houck31 offers potential solutions to this problem, such as eliminating the pressure on hospitals to perform at 100% on this measure by reporting performance within acceptable ranges (eg, 70%‐84% and 85%‐100%) Targeting a benchmark of 80% or a duration of 6 hours may also be appropriate. Finally, a 4‐hour benchmark has not been shown to benefit younger patients, so it is important to apply this target only to patients more than 65 years of age.

CHOICE OF ANTIBIOTIC

A retrospective review of 12,945 cases of inpatients with CAP found that, in comparison to ceftriaxone alone, initial antibiotic regimens consisting either of a second‐ or third‐generation cephalosporin plus a macrolide or of a fluoroquinolone alone were associated with an approximately 30% reduction in 30‐day mortality.32 Hence, current guidelines recommend the combination of a B‐lactam and macrolide, a B‐lactam and doxycycline, or a respiratory fluoroquinolone for inpatients with CAP not admitted to the ICU.3335

The results of subsequent studies supported the contention that guideline‐compliant antibiotics improve outcomes. A prospective multicenter study of a clinical pathway that encouraged use of either levofloxacin or cefuroxime plus azithromycin for the initial treatment of inpatient CAP showed significantly reduced mortality. Compared with any other antibiotic regimen, the odds ratio for death was 0.22 with the cephalosporin/macrolide combination and 0.43 with the fluoroquinolone. Of note, early mortality (within 5 days of admission) was not reduced by antibiotic choice.22 Similar results were found in a retrospective analysis, which found the odds of 30‐day mortality increased by 5.7 in patients not receiving guideline‐compliant therapy.36 A third study found guideline‐compliant antibiotics reduced the likelihood of a prolonged length of stay by 45%.20

Of note, data on the effectiveness of the cephalosporin/doxycycline combination are limited, and the major guidelines differ about whether this regimen is appropriate for inpatients with CAP.33, 34 Important findings from a recent retrospective cohort study showed that initial therapy with ceftriaxone plus doxycycline was associated with reduced inpatient mortality (OR = 0.26) as well as reduced 30‐day mortality (OR = 0.37) compared with other guideline‐compliant therapies for CAP.37 When patients who would not have been considered appropriate for initial doxycycline therapy (those resident in nursing homes, with aspiration pneumonia, or in the ICU) were excluded, a large reduction in inpatient mortality remained (OR = 0.17), without any increase in length of stay or readmission rate. Interestingly, this study suggests the potential superiority of this regimen, though a randomized controlled trial is needed to confirm this. The current core measures do include doxycycline as an acceptable option for CAP therapy (see Table 1).

Currently, controversy remains about whether the benefit of these selected regimens results from their activity against atypical pathogens (Mycoplasma, Legionella, Chlamydia) and whether there is additional benefit from using combination antibiotic therapy.38, 39 Waterer40 described 225 inpatients with bacteremic pneumococcal pneumonia, noting the antibiotic regimen received during the first 24 hours of hospitalization. Patients were classified retrospectively into 3 groupssingle effective therapy (SET), dual effective therapy (DET), or more than dual effective therapy (MET)on the basis of the concordance of pneumococcal sensitivity with the initial antibiotics. Patients on 2 antibiotics were classified in the DET group if the organism was sensitive to both and in the SET group if the organism was resistant to 1 of the 2. Those in the MET group were analyzed separately, as they were found to have a higher baseline severity of illness based on the PSI score; the SET and DET groups were equivalent.

Surprisingly, the SET group was found to have a 3‐fold increase in inpatient mortality; adjustment for severity of illness increased the odds ratio for death to 6.4. Of note, all deaths were in the most severely ill patients (PSI IV‐V). The protective effects of receiving DET were not specifically limited to those receiving a macrolide as the second agent, and multivariate analysis did not find coverage of atypical organisms to be an independent predictor of mortality.

A recent prospective multicenter trial of 844 patients with bacteremic pneumococcal pneumonia at 21 hospitals confirmed these findings.41 A significant 14‐day survival advantage (23% versus 55%) was found in the subgroup of critically ill patients who received at least 2 effective antibiotics. Though survival benefit was restricted to the sickest patients, severity of illness was similar among the groups.

The specific importance of macrolides in combination therapy remains under investigation. A review of a database of inpatients with bacteremic pneumococcal pneumonia over a 10‐year period found that 58% received initial empiric therapy with a B‐lactam/macrolide combination and 42% received B‐lactam without a macrolide (though other antibiotic combinations were not excluded).42 After logistic regression analysis, the investigators found a relative reduction in inpatient mortality of 60% in the patients receiving combination therapy with macrolides. Unfortunately, neither comparison to fluoroquinolone monotherapy nor risk stratification by PSI was reported. A similar study from Canada that did stratify for risk confirmed a mortality benefit of combination therapy.43

A subsequent, extremely large study of more than 44,000 patients from a hospital claims‐made database lent support to these findings.44 This study included all CAP patients regardless of microbiology and was not restricted to those with bacteremia. Outcomes among groups receiving monotherapy with any of the standard agents for CAP were compared with those in groups receiving combination therapy with a macrolide as the second agent. Statistically significant reductions in 30‐day mortality were observed in all groups receiving dual therapy with macrolides. Consistent with other studies, the benefit applied only to patients with more severe CAP. The percentage of patients with bacteremia was not specified.

Of note, this study did not allow direct comparison of fluoroquinolone monotherapy to combination therapy with a B‐lactam and a macrolide. However, the fluoroquinolone/macrolide combination conferred no additional benefit beyond fluoroquinolone monotherapy when adjusted for severity of illness or age. This implies that fluoroquinolone monotherapy is adequate, at least in some subpopulations. This is consistent with initial studies that established the superiority of the antibiotic combinations recommended by the guidelines.20, 22, 32

The potential benefit of combination therapy appears limited to patients with higher severity of illness and pneumococcal bacteremia. However, outcomes are affected by the antibiotic regimen selected in the initial 24‐48 hours of hospitalization, before results of blood cultures are routinely available. At present, clinical prediction of patients who will benefit from combination therapy is difficult.

Coverage of undiagnosed mixed infections with atypical organisms is probably not a major factor benefiting patients receiving combination therapy. Several recent meta‐analyses found no reduction in mortality or the rate of clinical failure among patients receiving antibiotics covering atypical organisms compared with those for patients whose regimens did not have such coverage.4547 Subgroups of patients with Legionella pneumonia do benefit from antibiotics with targeted activity against atypical organisms, but fewer than 1% of all patients were so identified. Evidence for antibiotic synergy is similarly lacking.48, 49 The immunomodulatory effects of macrolides, which decrease cytokine production and inflammation and subsequently reduce the severity of lung injury and other complications of sepsis, are considered potential factors in the reduction of mortality.50

The definition of severe CAP and the indications for ICU admission remain controversial, evidence for which is reviewed elsewhere.34, 51, 52 Antibiotic recommendations for ICU patients are included in Table 1 for completeness, but a detailed review of the evidence is lacking because current guidelines are based on consensus opinion.34 The use of fluoroquinolone monotherapy in severe CAP is not currently recommended because of limitations of the existing evidence. The majority of quinolone trials have excluded severely ill patients, and approval trials of newer respiratory fluoroquinolones have used levofloxacin as a comparator. Studies comparing fluoroquinolones typically allowed investigators in the B‐lactam arm the option of adding macrolides or tetracycline at their discretion. In addition, such trials have been designed as noniferiority trials.38 Clearly, randomized controlled trials are needed to resolve this issue.

Currently, selecting appropriate antibiotics should follow established guidelines, with consideration of using combination therapy for patients with a higher severity of illness. Emphasis on this measure should be stronger than that on antibiotic timing, as the bulk of the evidence favors significant mortality reduction from following guidelines for antibiotic therapy.

VACCINATION

Guidelines recommend all eligible adults hospitalized with CAP receive pneumococcal vaccination on discharge,3335, 53 though there is no evidence this reduces the incidence of pneumonia or death.54, 55 Retrospective studies have shown reduced incidence of invasive disease (bacteremia and meningitis), but not of other end points.5457 The estimated mortality from pneumococcal bacteremia remain as high as 20%‐30%, with no evidence that this rate has decreased over the last 30 years.5861 Despite this, a recent meta‐analysis from the Cochrane database that included only randomized, controlled trials (75,197 patients in 15 trials) was unable to show significant reductions in all‐cause pneumonia or mortality for vaccinated subjects.62 Cohort studies, evaluated separately in this analysis, showed an efficacy of 53% in reducing the incidence of invasive pneumococcal disease. Given the relatively low incidence of invasive disease in the general population, the number needed to treat was estimated at 20,000, or 4000 if only older patients were considered. A subsequent retrospective cohort study showed no reduction in pneumonia hospitalizations, cases of outpatient pneumonia, or mortality among 45,365 elderly vaccinees.56 Some specific subgroups may benefit, however. Vaccinated patients with chronic lung disease did show a reduction in hospitalization for pneumonia (RR 0.57 [0.38‐0.84]) and in mortality (RR 0.7 [0.56‐0.9]) in a retrospective study of HMO patients older than age 65.63

It is of interest that since the licensure of the pediatric 7‐valent protein‐polysaccharide conjugate vaccine in 2000, the incidence of invasive pneumococcal disease among adults has dropped significantly. Overall reduction in invasive disease in adults more than 50 years old was 11% from 1998 to 2003 (relative risk reduction [RRR] = 28%). This is likely the result of decreased transmission from colonized or infected children and not a coincidental increase in adult pneumococcal vaccination, as the rates of disease caused by the 16 strains unique to the 23‐valent vaccine did not change.64, 65 The overall reduction in the incidence of invasive disease is still superior with the adult vaccine, up to 30% in vaccinated subjects (RRR = 44%).56 Invasive disease caused specifically by penicillin‐nonsusceptible serotypes has dropped by 49% in the elderly since introduction of the vaccine.66 Thus, the combined impact of the 2 vaccines may be significant. It is not yet clear what effect, if any, the 7‐valent vaccine will have on the hospitalization rate or mortality.

In contrast to the results for pneumococcal vaccination, studies of the benefits of influenza vaccination have shown clear and consistent reductions in mortality, respiratory illness, hospitalization, and pneumonia, especially among patients with comorbidities.6771 Cost effectiveness has been demonstrated for all populations,72, 73 and the reduction in mortality among high‐risk patients younger than age 65 has been estimated to be as high as 78%.68 Among the elderly, reduction in mortality of about 50% has been reported, along with 20%‐30% reductions in hospitalizations for pneumonia, influenza, cardiac disease, and stroke.70 Reduced incidence of pneumonia in vaccinated patients has even been documented among elderly patients without specific comorbidities.67 Annual revaccination has the most significant impact on mortality.74

The pneumococcal vaccine remains important in the effort to reduce the severity of and complications from invasive pneumococcal disease in the elderly, but the lack of significant benefits on hard end points such as mortality or hospitalizations makes it a less robust measure of quality pneumonia care. In contrast, influenza vaccination has a much larger impact on outcomes in the population at risk. Emphasis should be shifted from pneumococcal to influenza vaccine in pneumonia performance measures.

OXYGENATION ASSESSMENT

It seems intuitive that oxygenation assessment is important in the initial evaluation of patients with CAP, though there is not direct evidence to support this. The recommendation for oxygenation assessment in the published guidelines for CAP is by consensus.3335 Documented hypoxemia is associated with increased pneumonia‐related mortality,17, 75 and clinical judgment does not adequately predict hypoxemia.76 Though the assessment of oxygenation has been found to vary widely among practitioners,77 performance has remained consistent since the advent of monitoring and reporting of quality measures, with compliance rates of 99%.4, 7 Monitoring performance of this measure should continue, though high compliance rates limit its ability to discriminate among institutions.

SMOKING CESSATION COUNSELING

Counseling patients to stop smoking was found to be modestly (2%) but statistically significantly effective in promoting abstinence at 1 year.78 In its report on treating tobacco use, the U.S. Public Health Services recommended that all smokers receive hospital‐ and system‐based interventions at every visit.79 As part of the Pneumonia Patient Outcomes Research Team (PORT) study, smokers with pneumonia underwent a tobacco cessation interview. Though only 15% of these patients quit smoking, 93% of those who quit did so at the time they developed CAP.80 A retrospective study of patients with bacteremic pneumococcal pneumonia found tobacco exposure, including passive smoking, to be a strong independent risk factor for invasive disease.81 The most recent CAP guidelines from the Infectious Disease Society of America (IDSA) recommend smoking cessation counseling for all hospitalized patients who smoke.33 However, hospitals are not likely to have the impact that a more comprehensive, outpatient‐based smoking cessation program would. Without ongoing support, counseling, and pharmacotherapy, the effects of an intervention would be expected to be small.79 Though evidence of benefit is limited, smoking cessation interventions should be encouraged at all sites of care. Quality care merits this regardless of admitting diagnosis, but benefits specific to CAP outcomes have not yet been demonstrated.

CONCLUSIONS

The burden of illness caused by CAP mandates that clinicians strive to deliver the highest quality of care to afflicted patients. Critical evaluation of the strength of the evidence will continue to guide such endeavors, and changes in practice will follow as new information surfaces. Standards of care, as adopted by consensus groups such as the IDSA and American Thoracic Society, will continue to inform the practice of hospitalists.

How quality is defined for public reporting requires particularly careful assessment. The definition of quality should be based on evidence more rigorous than that ascribed to consensus guidelines. Within the profession, guidelines offer reasonable standards of care and delineate areas for further research and are invaluable tools for practicing clinicians. In the public arena, however, proclaiming practices as good or bad sets expectations of health care consumers not educated in the nuances of evaluating clinical evidence and can unfairly bias them against conscientious and effective providers whose standards reflect different interpretations of controversial issues. Regulatory agencies should publicly target interventions using only the most solid evidentiary foundation while internally striving to monitor the effects of different practice patterns and report measurable differences in outcomes revealed by careful investigation. Areas where controversy remains should be the primary targets of further research but should not be offered as benchmarks for public scrutiny until the medical community has settled on a position.

Furthermore, when evidence remains questionable, financial incentives should be linked to performance indicators with extreme caution. It would be counterproductive if health care organizations, driven to achieve optimal antibiotic timing to obtain payment updates from CMS, began to administer antibiotics prior to completing workups on all patients with respiratory complaints, as this would likely lead to antibiotic overuse. Similarly, institutions pushed to collect blood cultures before antibiotics are given may inappropriately delay administration in order to perform well on quality measures, resulting in potential harm to patients.

The measures of quality care for CAP for which the evidence on outcomes is the most convincing are antibiotic selection (mortality benefit, reduction in LOS) and influenza vaccination (mortality benefit, reduction in hospitalizations, reduction in respiratory illness). Antibiotic timing also shows a smaller but convincing reduction in mortality, though the advantages of receiving antibiotics within 4 hours instead of 8 hours are not clearly established for younger patients. These measures should be emphasized most heavily in the arena of public reporting and incentives for quality care, with additions and modifications guided by emerging evidence. Revision of the other measures to conform with current evidence would allow public reporting to more accurately reflect quality.

The quality movement has spawned efforts to define and measure best practices for clinical conditions commonly cared for by hospitalists. Pneumonia is the most frequent infectious cause of death in the United States, and it accounts for more than 1 million hospitalizations annually at an estimated annual cost of $12.2 billion, most of it incurred by inpatients.1 The morbidity and mortality of the elderly are particularly burdensome.2, 3 For these reasons, attention has been focused on improving the quality of care of inpatients with community‐acquired pneumonia (CAP).

Credentialing agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require hospitals to report performance on predefined core measures of pneumonia care that they have identified as best practices (see Table 1).4, 5 The performance of individual organizations on these measures is now publicly reported at a website (www.hospitalcompare.hhs.gov) sponsored by the U.S. Department of Health and Human Services in conjunction with the Hospital Quality Alliance. Similar information is available at JCAHO's www.qualitycheck.org. Health care consumers can review quality data from the institution of their choice and compare the performance of various hospitals. The Centers for Medicare & Medicaid Services (CMS) provides financial incentives for the public reporting of such data and distributed $8.85 million to the top‐performing hospitals participating in a demonstration project in 2005.68 Voluntary reporting of performance on quality measures by individual physicians,9 as well as hospitals, is now being encouraged. As congress currently considers implementing pay for performance measures as a means to improve physician reimbursement, reporting will ultimately be linked to physician payments.

Performance on core measures for pneumonia is less consistent across hospitals than the other conditions currently being monitored.7 It is instructive, then, to review the evidence base for the existing pneumonia quality measures, which can inform decisions about prioritizing interventions to provide the most effective care for inpatients with CAP.

BLOOD CULTURES

In a large multicenter retrospective study of Medicare patients hospitalized with CAP, Meehan et al.10 found the performance of blood cultures within 24 hours of arrival to be associated with reduced 30‐day mortality. Despite the large sample size of more than 14,000 patients, the risk‐adjusted mortality reduction was of only borderline significance (RR 0.9 [0.81‐1.00]). The unadjusted data did not show a significant mortality reduction. Notably, collection of blood cultures prior to antibiotic administration did not affect mortality, even excluding patients receiving prehospital antibiotics.

A smaller review of 38 U.S. academic medical centers showed relatively high compliance with blood culture performance, but no mortality reduction, even after adjustment for severity of illness. Similarly, performing blood cultures before administration of antibiotics yielded no significant effect.11

Several studies call into question the clinical utility of performing blood cultures drawn from patients with CAP. Combined, these studies evaluated almost 3000 pneumonia patients who had blood cultures drawn; the likelihood of a change in therapy based on results was at most 5%. Among the patients with positive cultures, only 20%‐40% had a treatment change based on the result.1215

The more severely ill patients with CAP may benefit from blood cultures, though the findings reported in the literature vary.12, 16 Using the Pneumonia Severity Index (PSI) score17 to classify severity of illness, an observational study of 209 inpatients with CAP found the yield of blood cultures increased from 10% in the lowest‐risk groups to 27% in the most severely ill.16 In contrast, two larger studies with a combined enrollment of almost 14,000 patients were unable to demonstrate a difference in the incidence of bacteremia despite adjustment for the PSI score.12, 18 It is clear from these and other studies that patients in PSI classes I‐III derive very little benefit from the performance of blood cultures.12, 16, 19

Metersky et al.18 described a prospectively validated risk assessment tool that reliably predicted bacteremia in Medicare patients with CAP and explored its utility in reducing unnecessary blood cultures. Independent risk factors for bacteremia included prior antibiotic use, liver disease, hypotension, tachycardia, fever or hypothermia, BUN > 30 mg/dL, sodium < 130 mmol/L, and WBC < 5000 or > 20,000/mm². Use of this tool predicted bacteremia in 89% of patients and avoided 39% of unnecessary blood cultures. The authors also tested a modified version of the tool that excluded the laboratory abnormalities, so rapid assessment could be made at the initial patient presentation. This version advocated a single blood culture for most patients, and 2 blood cultures for patients with 2 or more risk factors. The modified tool accurately identified 88% of the patients with bacteremia and enabled a 44% reduction in unnecessary cultures.

In summary, blood cultures occasionally provide useful clinical information about etiology and resistance patterns, but they do not seem to reliably influence therapeutic decisions. It seems inappropriate to recommend against their use in practice, but they are not a solid benchmark for evidence‐based quality care. Measures that mandate risk assessment of all inpatients with CAP and require blood cultures only for older patients or those judged at high risk by PSI may better reflect quality. Alternatively, performing blood cultures on patients deemed to be high risk by the model of Metersky et al.18 may suffice.

ANTIBIOTIC TIMING

In a study of Medicare patients by Meehan et al.,10 the 30‐day mortality rate was reduced by 15% in the subset of patients who received antibiotics within 8 hours of arrival at the hospital. However, a trend toward mortality reduction was noted for those receiving antibiotics as early as 6 hours after arrival. Rapid administration of antibiotics was thus deemed an important measure of the quality of care of patients with CAP.

Additional studies attempted to confirm this observation. Battleman et al.20 evaluated 700 patients admitted for CAP through the emergency department. They found that a delay of more than 8 hours in the administration of antibiotics was correlated with a prolonged inpatient stay. Mortality rates were not reported. Achieving rapid delivery of antibiotics was closely linked to administration of the first dose of antibiotics in the emergency department.

Conversely, a large retrospective review by Dedier et al.11 found no reduction in inpatient mortality or in length of stay based on rapid antibiotic delivery, despite adjustment for severity of illness. They did not evaluate 30‐day mortality.

The effect of antibiotic timing on the time to clinical stability has also been investigated. Clinical stability was defined as 24 hours of a systolic blood pressure 90 mm Hg, heart rate 100 beats/min, respiratory rate 24 breaths/min, temperature 38.3C (101F), room air oxygen saturation 90%, and the ability to eat. Silber et al.,21 in a review of the records of 409 inpatients with moderate to severe CAP by PSI score, compared patients receiving antibiotics less than 4 hours, between 4 and 8 hours, and more than 8 hours after hospital admission. There was no difference between groups in time to clinical stability, even with adjustment for PSI.

Marrie and Wu22 attempted to define the factors that influenced inpatient mortality of patients with CAP not admitted to the intensive care unit (ICU). In a prospective study of 3043 patients evaluating a clinical pathway, a multivariate analysis showed antibiotic administration within 4 hours was not correlated with reduced mortality.

Although most studies supporting rapid antibiotic delivery used a target of 8 hours, administration in less than 4 hours is the consensus standard for pneumonia care set by CMS and JCAHO.23, 24

A benefit of timing antibiotic administration less than 4 hours after admission has been confirmed by a single, very large retrospective study of Medicare patients at least 65 years old.25 Analysis of a random sample of more than 18,000 patients with CAP who had not received prehospital antibiotics showed that the relative risk reduction for inpatient mortality was 15% in the group receiving antibiotics within 4 hours. Thirty‐day mortality was similarly reduced, and benefits continued for every hour of early antibiotic administration up to 9 hours.

The absolute risk reduction was small, however (0.6%), yielding a number needed to treat of 167 patients to prevent 1 death.

Randomized controlled trials, which would more definitively address the issue of antibiotic timing, are unlikely, as intentionally delaying administration of antibiotics to patients with known CAP is unethical. Hence, reliance on observational data must suffice. Intuitively, it makes sense to begin treatment of a bacterial infection at the earliest time possible. However, it is also known that not all patients present in a typical fashion, and diagnosis is uncertain at least 20% of the time.26 Anecdotal reports suggest that incentivizing physicians on performance measures encourages premature administration of empiric antibiotics to all patients presenting with cough, prior to confirmation of pneumonia.27, 28 Such practices promote further antibiotic resistance, arguably a larger health issue than delay in antibiotic delivery.29, 30

Houck31 offers potential solutions to this problem, such as eliminating the pressure on hospitals to perform at 100% on this measure by reporting performance within acceptable ranges (eg, 70%‐84% and 85%‐100%) Targeting a benchmark of 80% or a duration of 6 hours may also be appropriate. Finally, a 4‐hour benchmark has not been shown to benefit younger patients, so it is important to apply this target only to patients more than 65 years of age.

CHOICE OF ANTIBIOTIC

A retrospective review of 12,945 cases of inpatients with CAP found that, in comparison to ceftriaxone alone, initial antibiotic regimens consisting either of a second‐ or third‐generation cephalosporin plus a macrolide or of a fluoroquinolone alone were associated with an approximately 30% reduction in 30‐day mortality.32 Hence, current guidelines recommend the combination of a B‐lactam and macrolide, a B‐lactam and doxycycline, or a respiratory fluoroquinolone for inpatients with CAP not admitted to the ICU.3335

The results of subsequent studies supported the contention that guideline‐compliant antibiotics improve outcomes. A prospective multicenter study of a clinical pathway that encouraged use of either levofloxacin or cefuroxime plus azithromycin for the initial treatment of inpatient CAP showed significantly reduced mortality. Compared with any other antibiotic regimen, the odds ratio for death was 0.22 with the cephalosporin/macrolide combination and 0.43 with the fluoroquinolone. Of note, early mortality (within 5 days of admission) was not reduced by antibiotic choice.22 Similar results were found in a retrospective analysis, which found the odds of 30‐day mortality increased by 5.7 in patients not receiving guideline‐compliant therapy.36 A third study found guideline‐compliant antibiotics reduced the likelihood of a prolonged length of stay by 45%.20

Of note, data on the effectiveness of the cephalosporin/doxycycline combination are limited, and the major guidelines differ about whether this regimen is appropriate for inpatients with CAP.33, 34 Important findings from a recent retrospective cohort study showed that initial therapy with ceftriaxone plus doxycycline was associated with reduced inpatient mortality (OR = 0.26) as well as reduced 30‐day mortality (OR = 0.37) compared with other guideline‐compliant therapies for CAP.37 When patients who would not have been considered appropriate for initial doxycycline therapy (those resident in nursing homes, with aspiration pneumonia, or in the ICU) were excluded, a large reduction in inpatient mortality remained (OR = 0.17), without any increase in length of stay or readmission rate. Interestingly, this study suggests the potential superiority of this regimen, though a randomized controlled trial is needed to confirm this. The current core measures do include doxycycline as an acceptable option for CAP therapy (see Table 1).

Currently, controversy remains about whether the benefit of these selected regimens results from their activity against atypical pathogens (Mycoplasma, Legionella, Chlamydia) and whether there is additional benefit from using combination antibiotic therapy.38, 39 Waterer40 described 225 inpatients with bacteremic pneumococcal pneumonia, noting the antibiotic regimen received during the first 24 hours of hospitalization. Patients were classified retrospectively into 3 groupssingle effective therapy (SET), dual effective therapy (DET), or more than dual effective therapy (MET)on the basis of the concordance of pneumococcal sensitivity with the initial antibiotics. Patients on 2 antibiotics were classified in the DET group if the organism was sensitive to both and in the SET group if the organism was resistant to 1 of the 2. Those in the MET group were analyzed separately, as they were found to have a higher baseline severity of illness based on the PSI score; the SET and DET groups were equivalent.

Surprisingly, the SET group was found to have a 3‐fold increase in inpatient mortality; adjustment for severity of illness increased the odds ratio for death to 6.4. Of note, all deaths were in the most severely ill patients (PSI IV‐V). The protective effects of receiving DET were not specifically limited to those receiving a macrolide as the second agent, and multivariate analysis did not find coverage of atypical organisms to be an independent predictor of mortality.

A recent prospective multicenter trial of 844 patients with bacteremic pneumococcal pneumonia at 21 hospitals confirmed these findings.41 A significant 14‐day survival advantage (23% versus 55%) was found in the subgroup of critically ill patients who received at least 2 effective antibiotics. Though survival benefit was restricted to the sickest patients, severity of illness was similar among the groups.

The specific importance of macrolides in combination therapy remains under investigation. A review of a database of inpatients with bacteremic pneumococcal pneumonia over a 10‐year period found that 58% received initial empiric therapy with a B‐lactam/macrolide combination and 42% received B‐lactam without a macrolide (though other antibiotic combinations were not excluded).42 After logistic regression analysis, the investigators found a relative reduction in inpatient mortality of 60% in the patients receiving combination therapy with macrolides. Unfortunately, neither comparison to fluoroquinolone monotherapy nor risk stratification by PSI was reported. A similar study from Canada that did stratify for risk confirmed a mortality benefit of combination therapy.43

A subsequent, extremely large study of more than 44,000 patients from a hospital claims‐made database lent support to these findings.44 This study included all CAP patients regardless of microbiology and was not restricted to those with bacteremia. Outcomes among groups receiving monotherapy with any of the standard agents for CAP were compared with those in groups receiving combination therapy with a macrolide as the second agent. Statistically significant reductions in 30‐day mortality were observed in all groups receiving dual therapy with macrolides. Consistent with other studies, the benefit applied only to patients with more severe CAP. The percentage of patients with bacteremia was not specified.

Of note, this study did not allow direct comparison of fluoroquinolone monotherapy to combination therapy with a B‐lactam and a macrolide. However, the fluoroquinolone/macrolide combination conferred no additional benefit beyond fluoroquinolone monotherapy when adjusted for severity of illness or age. This implies that fluoroquinolone monotherapy is adequate, at least in some subpopulations. This is consistent with initial studies that established the superiority of the antibiotic combinations recommended by the guidelines.20, 22, 32

The potential benefit of combination therapy appears limited to patients with higher severity of illness and pneumococcal bacteremia. However, outcomes are affected by the antibiotic regimen selected in the initial 24‐48 hours of hospitalization, before results of blood cultures are routinely available. At present, clinical prediction of patients who will benefit from combination therapy is difficult.

Coverage of undiagnosed mixed infections with atypical organisms is probably not a major factor benefiting patients receiving combination therapy. Several recent meta‐analyses found no reduction in mortality or the rate of clinical failure among patients receiving antibiotics covering atypical organisms compared with those for patients whose regimens did not have such coverage.4547 Subgroups of patients with Legionella pneumonia do benefit from antibiotics with targeted activity against atypical organisms, but fewer than 1% of all patients were so identified. Evidence for antibiotic synergy is similarly lacking.48, 49 The immunomodulatory effects of macrolides, which decrease cytokine production and inflammation and subsequently reduce the severity of lung injury and other complications of sepsis, are considered potential factors in the reduction of mortality.50

The definition of severe CAP and the indications for ICU admission remain controversial, evidence for which is reviewed elsewhere.34, 51, 52 Antibiotic recommendations for ICU patients are included in Table 1 for completeness, but a detailed review of the evidence is lacking because current guidelines are based on consensus opinion.34 The use of fluoroquinolone monotherapy in severe CAP is not currently recommended because of limitations of the existing evidence. The majority of quinolone trials have excluded severely ill patients, and approval trials of newer respiratory fluoroquinolones have used levofloxacin as a comparator. Studies comparing fluoroquinolones typically allowed investigators in the B‐lactam arm the option of adding macrolides or tetracycline at their discretion. In addition, such trials have been designed as noniferiority trials.38 Clearly, randomized controlled trials are needed to resolve this issue.

Currently, selecting appropriate antibiotics should follow established guidelines, with consideration of using combination therapy for patients with a higher severity of illness. Emphasis on this measure should be stronger than that on antibiotic timing, as the bulk of the evidence favors significant mortality reduction from following guidelines for antibiotic therapy.

VACCINATION

Guidelines recommend all eligible adults hospitalized with CAP receive pneumococcal vaccination on discharge,3335, 53 though there is no evidence this reduces the incidence of pneumonia or death.54, 55 Retrospective studies have shown reduced incidence of invasive disease (bacteremia and meningitis), but not of other end points.5457 The estimated mortality from pneumococcal bacteremia remain as high as 20%‐30%, with no evidence that this rate has decreased over the last 30 years.5861 Despite this, a recent meta‐analysis from the Cochrane database that included only randomized, controlled trials (75,197 patients in 15 trials) was unable to show significant reductions in all‐cause pneumonia or mortality for vaccinated subjects.62 Cohort studies, evaluated separately in this analysis, showed an efficacy of 53% in reducing the incidence of invasive pneumococcal disease. Given the relatively low incidence of invasive disease in the general population, the number needed to treat was estimated at 20,000, or 4000 if only older patients were considered. A subsequent retrospective cohort study showed no reduction in pneumonia hospitalizations, cases of outpatient pneumonia, or mortality among 45,365 elderly vaccinees.56 Some specific subgroups may benefit, however. Vaccinated patients with chronic lung disease did show a reduction in hospitalization for pneumonia (RR 0.57 [0.38‐0.84]) and in mortality (RR 0.7 [0.56‐0.9]) in a retrospective study of HMO patients older than age 65.63

It is of interest that since the licensure of the pediatric 7‐valent protein‐polysaccharide conjugate vaccine in 2000, the incidence of invasive pneumococcal disease among adults has dropped significantly. Overall reduction in invasive disease in adults more than 50 years old was 11% from 1998 to 2003 (relative risk reduction [RRR] = 28%). This is likely the result of decreased transmission from colonized or infected children and not a coincidental increase in adult pneumococcal vaccination, as the rates of disease caused by the 16 strains unique to the 23‐valent vaccine did not change.64, 65 The overall reduction in the incidence of invasive disease is still superior with the adult vaccine, up to 30% in vaccinated subjects (RRR = 44%).56 Invasive disease caused specifically by penicillin‐nonsusceptible serotypes has dropped by 49% in the elderly since introduction of the vaccine.66 Thus, the combined impact of the 2 vaccines may be significant. It is not yet clear what effect, if any, the 7‐valent vaccine will have on the hospitalization rate or mortality.

In contrast to the results for pneumococcal vaccination, studies of the benefits of influenza vaccination have shown clear and consistent reductions in mortality, respiratory illness, hospitalization, and pneumonia, especially among patients with comorbidities.6771 Cost effectiveness has been demonstrated for all populations,72, 73 and the reduction in mortality among high‐risk patients younger than age 65 has been estimated to be as high as 78%.68 Among the elderly, reduction in mortality of about 50% has been reported, along with 20%‐30% reductions in hospitalizations for pneumonia, influenza, cardiac disease, and stroke.70 Reduced incidence of pneumonia in vaccinated patients has even been documented among elderly patients without specific comorbidities.67 Annual revaccination has the most significant impact on mortality.74

The pneumococcal vaccine remains important in the effort to reduce the severity of and complications from invasive pneumococcal disease in the elderly, but the lack of significant benefits on hard end points such as mortality or hospitalizations makes it a less robust measure of quality pneumonia care. In contrast, influenza vaccination has a much larger impact on outcomes in the population at risk. Emphasis should be shifted from pneumococcal to influenza vaccine in pneumonia performance measures.

OXYGENATION ASSESSMENT

It seems intuitive that oxygenation assessment is important in the initial evaluation of patients with CAP, though there is not direct evidence to support this. The recommendation for oxygenation assessment in the published guidelines for CAP is by consensus.3335 Documented hypoxemia is associated with increased pneumonia‐related mortality,17, 75 and clinical judgment does not adequately predict hypoxemia.76 Though the assessment of oxygenation has been found to vary widely among practitioners,77 performance has remained consistent since the advent of monitoring and reporting of quality measures, with compliance rates of 99%.4, 7 Monitoring performance of this measure should continue, though high compliance rates limit its ability to discriminate among institutions.

SMOKING CESSATION COUNSELING

Counseling patients to stop smoking was found to be modestly (2%) but statistically significantly effective in promoting abstinence at 1 year.78 In its report on treating tobacco use, the U.S. Public Health Services recommended that all smokers receive hospital‐ and system‐based interventions at every visit.79 As part of the Pneumonia Patient Outcomes Research Team (PORT) study, smokers with pneumonia underwent a tobacco cessation interview. Though only 15% of these patients quit smoking, 93% of those who quit did so at the time they developed CAP.80 A retrospective study of patients with bacteremic pneumococcal pneumonia found tobacco exposure, including passive smoking, to be a strong independent risk factor for invasive disease.81 The most recent CAP guidelines from the Infectious Disease Society of America (IDSA) recommend smoking cessation counseling for all hospitalized patients who smoke.33 However, hospitals are not likely to have the impact that a more comprehensive, outpatient‐based smoking cessation program would. Without ongoing support, counseling, and pharmacotherapy, the effects of an intervention would be expected to be small.79 Though evidence of benefit is limited, smoking cessation interventions should be encouraged at all sites of care. Quality care merits this regardless of admitting diagnosis, but benefits specific to CAP outcomes have not yet been demonstrated.

CONCLUSIONS

The burden of illness caused by CAP mandates that clinicians strive to deliver the highest quality of care to afflicted patients. Critical evaluation of the strength of the evidence will continue to guide such endeavors, and changes in practice will follow as new information surfaces. Standards of care, as adopted by consensus groups such as the IDSA and American Thoracic Society, will continue to inform the practice of hospitalists.

How quality is defined for public reporting requires particularly careful assessment. The definition of quality should be based on evidence more rigorous than that ascribed to consensus guidelines. Within the profession, guidelines offer reasonable standards of care and delineate areas for further research and are invaluable tools for practicing clinicians. In the public arena, however, proclaiming practices as good or bad sets expectations of health care consumers not educated in the nuances of evaluating clinical evidence and can unfairly bias them against conscientious and effective providers whose standards reflect different interpretations of controversial issues. Regulatory agencies should publicly target interventions using only the most solid evidentiary foundation while internally striving to monitor the effects of different practice patterns and report measurable differences in outcomes revealed by careful investigation. Areas where controversy remains should be the primary targets of further research but should not be offered as benchmarks for public scrutiny until the medical community has settled on a position.

Furthermore, when evidence remains questionable, financial incentives should be linked to performance indicators with extreme caution. It would be counterproductive if health care organizations, driven to achieve optimal antibiotic timing to obtain payment updates from CMS, began to administer antibiotics prior to completing workups on all patients with respiratory complaints, as this would likely lead to antibiotic overuse. Similarly, institutions pushed to collect blood cultures before antibiotics are given may inappropriately delay administration in order to perform well on quality measures, resulting in potential harm to patients.

The measures of quality care for CAP for which the evidence on outcomes is the most convincing are antibiotic selection (mortality benefit, reduction in LOS) and influenza vaccination (mortality benefit, reduction in hospitalizations, reduction in respiratory illness). Antibiotic timing also shows a smaller but convincing reduction in mortality, though the advantages of receiving antibiotics within 4 hours instead of 8 hours are not clearly established for younger patients. These measures should be emphasized most heavily in the arena of public reporting and incentives for quality care, with additions and modifications guided by emerging evidence. Revision of the other measures to conform with current evidence would allow public reporting to more accurately reflect quality.

Cross‐cover is defined as an on‐call physician managing acute problems such as chest pain, dyspnea, and hypoxemia for patients primarily cared for by another physician. Cross‐cover problems are commonly encountered with hospitalized patients, and inappropriate evaluation and management can result in misdiagnosis. Residents in many internal medicine residency programs receive only informal instruction about how to manage cross‐cover problems, usually from senior medical residents. Unfortunately, instruction is often provided while a patient is experiencing a problem, a frequent occurrence in the chaotic circumstances of a stressful learning environment. Furthermore, the knowledge base, experience, and teaching skills of senior residents vary substantially, and typically senior residents receive no formal instruction to guide them in how or what to teach more junior residents. If formal instruction is provided to residents, it is typically through often poorly attended didactic lectures that have been shown to be an ineffective forum for acquiring skills or changing physician behavior.15

Although previous studies did find that educational interventions can improve confidence and increase knowledge about various aspects of residency training, many of these studies were not randomized,68 or they involved complex interventions requiring a significant amount of resident and teaching staff time.911 The few randomized studies that used simple educational interventions focused on outpatient education, but most of a resident's time is spent in an inpatient setting.1213

Therefore, we designed a simple, randomized educational intervention consisting of 2 formal small‐group, case‐based discussion sessions addressing 1 cross‐cover situation: a hospitalized patient with acute dyspnea. We hypothesized that the addition of small‐group sessions would improve intern knowledge about and confidence in managing acute dyspnea above that gained from a combination of informal education and formal but lecture‐based education.

METHODS

Thirty‐eight internal medicine residents in their first year of postgraduate training (interns) at the University of Michigan were approached to participate in the study. Twenty‐six interns signed informed consent forms and were randomized using a random number generator to receive either the standard education (the control group) or the standard education plus the educational intervention (the intervention group). The standard education was informal teaching by senior medical residents on the wards and a 1‐hour lecture on Approach to the Patient with Acute Dyspnea, taught by an attending physician from the Department of Pulmonary and Critical Care Medicine. The educational intervention included the standard education as well as 2 small‐group, case‐based interactive sessions on acute dyspnea management. Both sessions were developed and taught by the first author (T.M.R.), a third‐year resident in internal medicine. A senior resident taught the sessions to try to make the information more relevant and practical and to make asking questions less intimidating. The first session, which lasted 50 minutes, discussed cases of bronchospasm, pulmonary edema, and pulmonary embolism as causes of acute dyspnea. It addressed several concepts: knowing when and how quickly to evaluate a dyspneic patient, formulating a differential diagnosis, appropriately evaluating acute dyspnea, providing empiric therapy, and recognizing indications for intubation. The second small‐group session occurred approximately 1 month after the first session and lasted 30 minutes. In this session key concepts learned during the first session were reviewed, and a case of ventricular tachycardia presenting as acute dyspnea was discussed. In an effort to increase attendance, free food and drink were provided at each session, and participants were sent reminders via e‐mail and the paging system prior to each session.

All study participants completed pre‐ and postintervention surveys that assessed their knowledge of acute dyspnea management and their confidence in managing patients with this condition. The pretests were conducted just before the first small‐group session was held. The post‐tests were conducted 4 months later. Knowledge was assessed by the score on the 45‐point test, which contained both open‐ and closed‐ended questions derived from 10 case‐based items. The number of points that a question was worth varied depending on how many elements made up a correct answer. For example, one question asked, What tests (if any) do you plan to order immediately after you examine the patient? As 3 tests should have been obtained (EKG, CXR, and ABG), this item had a maximum score of 3 points. Confidence was assessed by averaging 17 items scored on a 5‐point Likert scale (from strongly agree to strongly disagree). The items measured the physician's confidence in managing various aspects of the dyspneic patient (eg, confidence in knowing when to intubate a patient, when to obtain an ABG/CXR/EKG, and when to transfer a patient to the ICU). Data were analyzed using repeated‐measures analysis of variance. Primary analysis was based on the intention‐to‐treat principle, with alpha set to .05 (2‐sided). A secondary, per‐protocol analysis was also performed. In this analysis, study participants who attended both small‐group sessions (ie, completed the entire intervention) were compared with the control group. The protocol was approved by the institutional review board at the University of Michigan Health System.

RESULTS

All participants completed the study. Overall, only 3 of the 26 interns attended the lecture on Approach to the Patient with Acute Dyspnea. Fourteen of the 16 interns assigned to the intervention group attended 1 of the 2 small‐group sessions (11 attended the first session, and 10 attended the second session). Seven interns attended both sessions. The study period was 4 months. Both the intervention and control groups reported managing a similar number of patients with acute dyspnea, both prior to the study (mean of 5.9 in the intervention group and 7.4 in the control group, P = .51) and at the end of study (mean 10.6 in the intervention group and 10.2 in the control group, P = .91). There was no significant difference in the total number of completed inpatient months (mean of 4.9 in the intervention group and 4.7 in the control group, P =. 32) or in the number of inpatient months completed prior to the start of the study (mean of 2 in the intervention group and 2.4 in the control group, P = .15).

Confidence

Subjects in both the intervention and control groups showed increased confidence over time. The mean score of the intervention group increased from 3.77 to 4.57 (a 21.2% increase) and that of the control group increased from 3.74 to 4.28 (a 14.4% increase). Although the trend over time was highly significant for both groups (P < .001), the effect of the intervention was not significant (P = .19). However, the power to detect a difference between the groups was low (0.25). In the per‐protocol analysis, there was no significant difference between the groups (P = .26; see Fig. 1).

Figure 1

Knowledge

In the primary analysis, results for knowledge were similar to those obtained for the confidence outcome. In the intervention group, the mean score increased from 35.6 to 38.3 (a 7.6% increase); in the control group, the mean increased from 36.2 to 38.2 (a 5.5% increase). Scores ranged from 31 to 42. Again, the trend for both groups was significant (P < .01), but the effect of the intervention was not significant (P = .65). The power to detect a difference between groups was again low (0.07). In the per‐protocol analysis a trend toward significance was seen, with mean scores increasing from 34.6 to 40.0, a 15.6% increase (P = .067; see Fig. 2).

Figure 2

DISCUSSION

Our randomized controlled trial found that intern confidence and knowledge about acute dyspnea management both increased significantly over time; however, no significant differences between the intervention and control groups were observed. The complete intervention was not administered to the vast majority of those in the intervention group, however, likely skewing results toward the null. As suggested by the per‐protocol analysis, there was a trend toward a significant increase in the knowledge of the interns who had received the entire intervention. This is similar to results found in a randomized study by Schroy et al., which demonstrated a significant increase in resident knowledge of colorectal cancer screening after an educational intervention that used an interactive, case‐based seminar.13

Our study had several strengths. First, we employed the most robust design to detect efficacy, a randomized controlled study design. Second, we had complete follow‐up because all participants finished the study. Finally, our intervention is easily reproducible.

Our findings should also be considered within the context of several limitations. Despite the use of a random number generator, the control and intervention groups were unequal in number, which may have affected the results, particularly with such a small sample size.

Second, the intervention did not occur until 3 months after the start of each participant's internship. The intention was to implement the intervention at the start of internship, but institutional review board approval did not occur for an additional 3 months. This late timing might have been unfortunate because interns may already have had an established management plan for acute dyspnea, making their behavior more difficult to alter, even with additional education.

Third, because we were unaware of available test instruments to assess resident knowledge of acute dyspnea in the hospitalized patient, we needed to create our own. Unfortunately, the instrument yielded only a small variance in test scores, which may have made it difficult to detect an effect on scores if present.

Fourth, attendance at each session was suboptimal, and thus the complete intervention was not administered to the vast majority of those in the intervention group. Because the first small‐group session was the main teaching session, interns who only attended the second session were exposed to just one case discussion and only a review, rather than a full formal discussion, of the material presented during the first session. Therefore, it is not known if the intervention really had no effect or if no differences were detected simply because the complete intervention was not received. The trend toward significance observed in the per‐protocol analysis suggests that compliance with the intervention may be the key to improving knowledge.

Given the small differences observed in this study, future interventions ideally should use a more sensitive testing instrument, a larger sample, and a more powerful intervention that occurs early in training. Future efforts should also be designed to improve attendance at educational interventions. In the setting of reduced resident work hours and increased demands on resident time, this will prove to be a true challenge for all educators and residency programs.

Cross‐cover is defined as an on‐call physician managing acute problems such as chest pain, dyspnea, and hypoxemia for patients primarily cared for by another physician. Cross‐cover problems are commonly encountered with hospitalized patients, and inappropriate evaluation and management can result in misdiagnosis. Residents in many internal medicine residency programs receive only informal instruction about how to manage cross‐cover problems, usually from senior medical residents. Unfortunately, instruction is often provided while a patient is experiencing a problem, a frequent occurrence in the chaotic circumstances of a stressful learning environment. Furthermore, the knowledge base, experience, and teaching skills of senior residents vary substantially, and typically senior residents receive no formal instruction to guide them in how or what to teach more junior residents. If formal instruction is provided to residents, it is typically through often poorly attended didactic lectures that have been shown to be an ineffective forum for acquiring skills or changing physician behavior.15

Although previous studies did find that educational interventions can improve confidence and increase knowledge about various aspects of residency training, many of these studies were not randomized,68 or they involved complex interventions requiring a significant amount of resident and teaching staff time.911 The few randomized studies that used simple educational interventions focused on outpatient education, but most of a resident's time is spent in an inpatient setting.1213

Therefore, we designed a simple, randomized educational intervention consisting of 2 formal small‐group, case‐based discussion sessions addressing 1 cross‐cover situation: a hospitalized patient with acute dyspnea. We hypothesized that the addition of small‐group sessions would improve intern knowledge about and confidence in managing acute dyspnea above that gained from a combination of informal education and formal but lecture‐based education.

METHODS

Thirty‐eight internal medicine residents in their first year of postgraduate training (interns) at the University of Michigan were approached to participate in the study. Twenty‐six interns signed informed consent forms and were randomized using a random number generator to receive either the standard education (the control group) or the standard education plus the educational intervention (the intervention group). The standard education was informal teaching by senior medical residents on the wards and a 1‐hour lecture on Approach to the Patient with Acute Dyspnea, taught by an attending physician from the Department of Pulmonary and Critical Care Medicine. The educational intervention included the standard education as well as 2 small‐group, case‐based interactive sessions on acute dyspnea management. Both sessions were developed and taught by the first author (T.M.R.), a third‐year resident in internal medicine. A senior resident taught the sessions to try to make the information more relevant and practical and to make asking questions less intimidating. The first session, which lasted 50 minutes, discussed cases of bronchospasm, pulmonary edema, and pulmonary embolism as causes of acute dyspnea. It addressed several concepts: knowing when and how quickly to evaluate a dyspneic patient, formulating a differential diagnosis, appropriately evaluating acute dyspnea, providing empiric therapy, and recognizing indications for intubation. The second small‐group session occurred approximately 1 month after the first session and lasted 30 minutes. In this session key concepts learned during the first session were reviewed, and a case of ventricular tachycardia presenting as acute dyspnea was discussed. In an effort to increase attendance, free food and drink were provided at each session, and participants were sent reminders via e‐mail and the paging system prior to each session.

All study participants completed pre‐ and postintervention surveys that assessed their knowledge of acute dyspnea management and their confidence in managing patients with this condition. The pretests were conducted just before the first small‐group session was held. The post‐tests were conducted 4 months later. Knowledge was assessed by the score on the 45‐point test, which contained both open‐ and closed‐ended questions derived from 10 case‐based items. The number of points that a question was worth varied depending on how many elements made up a correct answer. For example, one question asked, What tests (if any) do you plan to order immediately after you examine the patient? As 3 tests should have been obtained (EKG, CXR, and ABG), this item had a maximum score of 3 points. Confidence was assessed by averaging 17 items scored on a 5‐point Likert scale (from strongly agree to strongly disagree). The items measured the physician's confidence in managing various aspects of the dyspneic patient (eg, confidence in knowing when to intubate a patient, when to obtain an ABG/CXR/EKG, and when to transfer a patient to the ICU). Data were analyzed using repeated‐measures analysis of variance. Primary analysis was based on the intention‐to‐treat principle, with alpha set to .05 (2‐sided). A secondary, per‐protocol analysis was also performed. In this analysis, study participants who attended both small‐group sessions (ie, completed the entire intervention) were compared with the control group. The protocol was approved by the institutional review board at the University of Michigan Health System.

RESULTS

All participants completed the study. Overall, only 3 of the 26 interns attended the lecture on Approach to the Patient with Acute Dyspnea. Fourteen of the 16 interns assigned to the intervention group attended 1 of the 2 small‐group sessions (11 attended the first session, and 10 attended the second session). Seven interns attended both sessions. The study period was 4 months. Both the intervention and control groups reported managing a similar number of patients with acute dyspnea, both prior to the study (mean of 5.9 in the intervention group and 7.4 in the control group, P = .51) and at the end of study (mean 10.6 in the intervention group and 10.2 in the control group, P = .91). There was no significant difference in the total number of completed inpatient months (mean of 4.9 in the intervention group and 4.7 in the control group, P =. 32) or in the number of inpatient months completed prior to the start of the study (mean of 2 in the intervention group and 2.4 in the control group, P = .15).

Confidence

Subjects in both the intervention and control groups showed increased confidence over time. The mean score of the intervention group increased from 3.77 to 4.57 (a 21.2% increase) and that of the control group increased from 3.74 to 4.28 (a 14.4% increase). Although the trend over time was highly significant for both groups (P < .001), the effect of the intervention was not significant (P = .19). However, the power to detect a difference between the groups was low (0.25). In the per‐protocol analysis, there was no significant difference between the groups (P = .26; see Fig. 1).

Figure 1

Knowledge

In the primary analysis, results for knowledge were similar to those obtained for the confidence outcome. In the intervention group, the mean score increased from 35.6 to 38.3 (a 7.6% increase); in the control group, the mean increased from 36.2 to 38.2 (a 5.5% increase). Scores ranged from 31 to 42. Again, the trend for both groups was significant (P < .01), but the effect of the intervention was not significant (P = .65). The power to detect a difference between groups was again low (0.07). In the per‐protocol analysis a trend toward significance was seen, with mean scores increasing from 34.6 to 40.0, a 15.6% increase (P = .067; see Fig. 2).

Figure 2

DISCUSSION

Our randomized controlled trial found that intern confidence and knowledge about acute dyspnea management both increased significantly over time; however, no significant differences between the intervention and control groups were observed. The complete intervention was not administered to the vast majority of those in the intervention group, however, likely skewing results toward the null. As suggested by the per‐protocol analysis, there was a trend toward a significant increase in the knowledge of the interns who had received the entire intervention. This is similar to results found in a randomized study by Schroy et al., which demonstrated a significant increase in resident knowledge of colorectal cancer screening after an educational intervention that used an interactive, case‐based seminar.13

Our study had several strengths. First, we employed the most robust design to detect efficacy, a randomized controlled study design. Second, we had complete follow‐up because all participants finished the study. Finally, our intervention is easily reproducible.

Our findings should also be considered within the context of several limitations. Despite the use of a random number generator, the control and intervention groups were unequal in number, which may have affected the results, particularly with such a small sample size.

Second, the intervention did not occur until 3 months after the start of each participant's internship. The intention was to implement the intervention at the start of internship, but institutional review board approval did not occur for an additional 3 months. This late timing might have been unfortunate because interns may already have had an established management plan for acute dyspnea, making their behavior more difficult to alter, even with additional education.

Third, because we were unaware of available test instruments to assess resident knowledge of acute dyspnea in the hospitalized patient, we needed to create our own. Unfortunately, the instrument yielded only a small variance in test scores, which may have made it difficult to detect an effect on scores if present.

Fourth, attendance at each session was suboptimal, and thus the complete intervention was not administered to the vast majority of those in the intervention group. Because the first small‐group session was the main teaching session, interns who only attended the second session were exposed to just one case discussion and only a review, rather than a full formal discussion, of the material presented during the first session. Therefore, it is not known if the intervention really had no effect or if no differences were detected simply because the complete intervention was not received. The trend toward significance observed in the per‐protocol analysis suggests that compliance with the intervention may be the key to improving knowledge.

Given the small differences observed in this study, future interventions ideally should use a more sensitive testing instrument, a larger sample, and a more powerful intervention that occurs early in training. Future efforts should also be designed to improve attendance at educational interventions. In the setting of reduced resident work hours and increased demands on resident time, this will prove to be a true challenge for all educators and residency programs.

Cross‐cover is defined as an on‐call physician managing acute problems such as chest pain, dyspnea, and hypoxemia for patients primarily cared for by another physician. Cross‐cover problems are commonly encountered with hospitalized patients, and inappropriate evaluation and management can result in misdiagnosis. Residents in many internal medicine residency programs receive only informal instruction about how to manage cross‐cover problems, usually from senior medical residents. Unfortunately, instruction is often provided while a patient is experiencing a problem, a frequent occurrence in the chaotic circumstances of a stressful learning environment. Furthermore, the knowledge base, experience, and teaching skills of senior residents vary substantially, and typically senior residents receive no formal instruction to guide them in how or what to teach more junior residents. If formal instruction is provided to residents, it is typically through often poorly attended didactic lectures that have been shown to be an ineffective forum for acquiring skills or changing physician behavior.15

Although previous studies did find that educational interventions can improve confidence and increase knowledge about various aspects of residency training, many of these studies were not randomized,68 or they involved complex interventions requiring a significant amount of resident and teaching staff time.911 The few randomized studies that used simple educational interventions focused on outpatient education, but most of a resident's time is spent in an inpatient setting.1213

Therefore, we designed a simple, randomized educational intervention consisting of 2 formal small‐group, case‐based discussion sessions addressing 1 cross‐cover situation: a hospitalized patient with acute dyspnea. We hypothesized that the addition of small‐group sessions would improve intern knowledge about and confidence in managing acute dyspnea above that gained from a combination of informal education and formal but lecture‐based education.

METHODS

Thirty‐eight internal medicine residents in their first year of postgraduate training (interns) at the University of Michigan were approached to participate in the study. Twenty‐six interns signed informed consent forms and were randomized using a random number generator to receive either the standard education (the control group) or the standard education plus the educational intervention (the intervention group). The standard education was informal teaching by senior medical residents on the wards and a 1‐hour lecture on Approach to the Patient with Acute Dyspnea, taught by an attending physician from the Department of Pulmonary and Critical Care Medicine. The educational intervention included the standard education as well as 2 small‐group, case‐based interactive sessions on acute dyspnea management. Both sessions were developed and taught by the first author (T.M.R.), a third‐year resident in internal medicine. A senior resident taught the sessions to try to make the information more relevant and practical and to make asking questions less intimidating. The first session, which lasted 50 minutes, discussed cases of bronchospasm, pulmonary edema, and pulmonary embolism as causes of acute dyspnea. It addressed several concepts: knowing when and how quickly to evaluate a dyspneic patient, formulating a differential diagnosis, appropriately evaluating acute dyspnea, providing empiric therapy, and recognizing indications for intubation. The second small‐group session occurred approximately 1 month after the first session and lasted 30 minutes. In this session key concepts learned during the first session were reviewed, and a case of ventricular tachycardia presenting as acute dyspnea was discussed. In an effort to increase attendance, free food and drink were provided at each session, and participants were sent reminders via e‐mail and the paging system prior to each session.

All study participants completed pre‐ and postintervention surveys that assessed their knowledge of acute dyspnea management and their confidence in managing patients with this condition. The pretests were conducted just before the first small‐group session was held. The post‐tests were conducted 4 months later. Knowledge was assessed by the score on the 45‐point test, which contained both open‐ and closed‐ended questions derived from 10 case‐based items. The number of points that a question was worth varied depending on how many elements made up a correct answer. For example, one question asked, What tests (if any) do you plan to order immediately after you examine the patient? As 3 tests should have been obtained (EKG, CXR, and ABG), this item had a maximum score of 3 points. Confidence was assessed by averaging 17 items scored on a 5‐point Likert scale (from strongly agree to strongly disagree). The items measured the physician's confidence in managing various aspects of the dyspneic patient (eg, confidence in knowing when to intubate a patient, when to obtain an ABG/CXR/EKG, and when to transfer a patient to the ICU). Data were analyzed using repeated‐measures analysis of variance. Primary analysis was based on the intention‐to‐treat principle, with alpha set to .05 (2‐sided). A secondary, per‐protocol analysis was also performed. In this analysis, study participants who attended both small‐group sessions (ie, completed the entire intervention) were compared with the control group. The protocol was approved by the institutional review board at the University of Michigan Health System.

RESULTS

All participants completed the study. Overall, only 3 of the 26 interns attended the lecture on Approach to the Patient with Acute Dyspnea. Fourteen of the 16 interns assigned to the intervention group attended 1 of the 2 small‐group sessions (11 attended the first session, and 10 attended the second session). Seven interns attended both sessions. The study period was 4 months. Both the intervention and control groups reported managing a similar number of patients with acute dyspnea, both prior to the study (mean of 5.9 in the intervention group and 7.4 in the control group, P = .51) and at the end of study (mean 10.6 in the intervention group and 10.2 in the control group, P = .91). There was no significant difference in the total number of completed inpatient months (mean of 4.9 in the intervention group and 4.7 in the control group, P =. 32) or in the number of inpatient months completed prior to the start of the study (mean of 2 in the intervention group and 2.4 in the control group, P = .15).

Confidence

Subjects in both the intervention and control groups showed increased confidence over time. The mean score of the intervention group increased from 3.77 to 4.57 (a 21.2% increase) and that of the control group increased from 3.74 to 4.28 (a 14.4% increase). Although the trend over time was highly significant for both groups (P < .001), the effect of the intervention was not significant (P = .19). However, the power to detect a difference between the groups was low (0.25). In the per‐protocol analysis, there was no significant difference between the groups (P = .26; see Fig. 1).

Figure 1

Knowledge

In the primary analysis, results for knowledge were similar to those obtained for the confidence outcome. In the intervention group, the mean score increased from 35.6 to 38.3 (a 7.6% increase); in the control group, the mean increased from 36.2 to 38.2 (a 5.5% increase). Scores ranged from 31 to 42. Again, the trend for both groups was significant (P < .01), but the effect of the intervention was not significant (P = .65). The power to detect a difference between groups was again low (0.07). In the per‐protocol analysis a trend toward significance was seen, with mean scores increasing from 34.6 to 40.0, a 15.6% increase (P = .067; see Fig. 2).

Figure 2

DISCUSSION

Our randomized controlled trial found that intern confidence and knowledge about acute dyspnea management both increased significantly over time; however, no significant differences between the intervention and control groups were observed. The complete intervention was not administered to the vast majority of those in the intervention group, however, likely skewing results toward the null. As suggested by the per‐protocol analysis, there was a trend toward a significant increase in the knowledge of the interns who had received the entire intervention. This is similar to results found in a randomized study by Schroy et al., which demonstrated a significant increase in resident knowledge of colorectal cancer screening after an educational intervention that used an interactive, case‐based seminar.13

Our study had several strengths. First, we employed the most robust design to detect efficacy, a randomized controlled study design. Second, we had complete follow‐up because all participants finished the study. Finally, our intervention is easily reproducible.

Our findings should also be considered within the context of several limitations. Despite the use of a random number generator, the control and intervention groups were unequal in number, which may have affected the results, particularly with such a small sample size.

Second, the intervention did not occur until 3 months after the start of each participant's internship. The intention was to implement the intervention at the start of internship, but institutional review board approval did not occur for an additional 3 months. This late timing might have been unfortunate because interns may already have had an established management plan for acute dyspnea, making their behavior more difficult to alter, even with additional education.

Third, because we were unaware of available test instruments to assess resident knowledge of acute dyspnea in the hospitalized patient, we needed to create our own. Unfortunately, the instrument yielded only a small variance in test scores, which may have made it difficult to detect an effect on scores if present.

Fourth, attendance at each session was suboptimal, and thus the complete intervention was not administered to the vast majority of those in the intervention group. Because the first small‐group session was the main teaching session, interns who only attended the second session were exposed to just one case discussion and only a review, rather than a full formal discussion, of the material presented during the first session. Therefore, it is not known if the intervention really had no effect or if no differences were detected simply because the complete intervention was not received. The trend toward significance observed in the per‐protocol analysis suggests that compliance with the intervention may be the key to improving knowledge.

Given the small differences observed in this study, future interventions ideally should use a more sensitive testing instrument, a larger sample, and a more powerful intervention that occurs early in training. Future efforts should also be designed to improve attendance at educational interventions. In the setting of reduced resident work hours and increased demands on resident time, this will prove to be a true challenge for all educators and residency programs.

Hospital discharge is a critical transition point for many inpatients. Patient recovery from diseases requiring hospitalization is frequently incomplete and requires ongoing management and evaluation after discharge. For hospitalists who focus their practice primarily on inpatient care, the handoff to the outpatient setting frequently involves a change in health care provider and care team. Changes in care environment and care goals can lead to adverse patient‐ and system‐level events.1 High‐risk patients with multiple medical issues and elderly patients are especially vulnerable to the consequences of ineffective discharge handoffs.2, 3

Several studies have identified the errors that commonly occur around the time of hospital discharge. Forster et al.4 found that 1 in 5 patients experiences an adverse event (defined as an injury resulting from medical management rather than from the underlying disease) in the transition from hospital to home. They also found that approximately 62% of adverse events could be either prevented or ameliorated.4 Roy et al. examined test results pending at the time of discharge and determined that posthospital providers were frequently unaware of pending test results, with a potentially serious clinical impact.5 In an analysis of adverse events at 2 large hospitals in the United Kingdom, Neale et al. found that almost 11% of those hospitalized had an adverse event, 18% of which were attributable to the discharge process.6

Communication of important transitional care issues to the posthospital care team and to the patient is essential to a safe transition. Studies by van Walraven et al. found that patient follow‐up with a physician who had access to the hospital discharge summary was associated with a decreased risk of rehospitalization.7 Patients not understanding discharge medications,8 dietary restrictions, or other lifestyle changes such as smoking cessation and exercise can lead to ineffective care transitions. Furthermore, the health system's barriers to effective patient self‐management may exacerbate the risk in the transition from the hospital setting.2, 913

In addition to the growing research literature that has identified gaps in the discharge process, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has included discharge instructions as a core performance measure in the care of heart failure patients. Hospital performance on this measure is reported publicly on the Centers for Medicare and Medicaid Services website (www.hospitalcompare.hhs.gov). Furthermore, the 2006 JCAHO patient safety goal of medication reconciliation recognizes the importance of preventing lapses in medication safety at points of care transition.14, 15 JCAHO now requires the development and implementation of processes to collect, review, reconcile, and document prescribed medications at all points of care transition, including hospital discharge.16

Older adults are considered more vulnerable to adverse events after discharge.8 They account for approximately 12% of the total U.S. population, but they make up 70% of hospitalized patients.17 With these factors in mind, the Society of Hospital Medicine (SHM) identified the elderly as a group especially vulnerable to the clinical care handoffs that occur in the hospital discharge process and therefore the patient population targeted in constructing the required elements of an ideal hospital discharge.

In addition to identifying a target patient population, inclusion of stakeholders primarily responsible for implementation is critical to developing a new process standard. In this instance, the hospitalist was identified as a critical architect of the development of the ideal discharge process, although clearly the hospitalist is just one of many people ultimately responsible for coordinating an effective hospital discharge. Finally, the organizations within which the elderly receive care and at which hospitalists practice are important partners in the implementation of systems of care that facilitate seamless care transitions.

In examining the myriad stakeholders involved in the discharge transitionthe patient, the hospitalist, other caregivers involved in hospital care, and the organizationSHM's Hospital Quality & Patient Safety (HQPS) Committee undertook an initiative to develop a practical list of important elements for hospitalists to include in the discharge of elderly inpatients, referred to in this article as the discharge checklist.

METHODS

In a process similar to that used by professional societies in the development of clinical guidelines, the SHM HQPS Committee used a combination of evidence‐based review and expert panels to develop a discharge checklist for elderly patients. Given that the focus of this project was a process improvement rather than a specific clinical condition, the SHM also believed it was critical to share the draft checklist with academic and community‐based practitioners knowledgeable in both the myriad logistical issues of and potential barriers to improving the discharge transition. The detailed process for checklist development is outlined below and summarized in Figure 1.

Figure 1

RESULTS

The final discharge checklist is shown in Figure 2. It contains required and optional data elements and processes for 3 types of discharge documents: the discharge summary, patient instructions, and communication (by phone, e‐mail, or fax) on the day of discharge to the receiving provider. Other documents, such as transfer orders for a rehabilitation facility or nursing home, were considered outside the scope of this project.

Figure 2

The literature review identified medications as a significant source of adverse events for patients upon hospital discharge.4, 8, 14, 1820 The expert panel and workshop participants all endorsed the need for additional detailed attention to reviewing and reconciling medications during the discharge process. The use of standardized tools was suggested by the group to improve the medication review process.21 The required elements include not only a list of discharge medications but also attention to high‐risk medications that require closer postdischarge follow‐up and monitoring (such as warfarin,22 diuretics, nephrotoxic medications, corticosteroids, hypoglycemic medications, and narcotic analgesics), reconciliation of the discharge medication regimen with preadmission medications and designation of medications as new, modified, or discontinued,23 and emphasis on assessing patient understanding of medication self‐management plans.24 Several published studies found that pharmacist oversight of discharge medications or postdischarge telephone calls improved patient outcomes.1820 However, not every health system has the resources and infrastructure necessary to implement these types of programs. Moreover, methods of implementation of each of these discharge elements were believed to be beyond the scope of this project, so pharmacist involvement was not specifically included in this checklist.

The expert panel and workshop participants found items related to cognition and functional status to be important for patients whose usual cognitive or functional status was changed or whose status at discharge was not within normal limits.25, 26 Clinicians seeing patients in follow‐up would then have an important reference point for evaluating progress and the need for additional home support or therapy. Patients with limited literacy or language barriers may need these issues assessed with the help of family members and/or translators to identify changes from their baseline level of functioning.

In addition, resuscitation status was viewed by the group as an important data element for some patients,27 particularly those who had been critically ill. Development of disease or population‐specific content, for example, for patients with heart failure or pneumonia, was also identified as critical to the safe discharge of elderly patient, with the understanding that there may be a need to modify and individualize the content for patients with complex conditions and multiple comorbidities.

The content of the hospital discharge summary deemphasized the need for a complete history of the present illness at the time of hospital admission or an exhaustive hospital course. Instead, it highlighted the need to identify a patient's condition at discharge, pending issues and interventions requiring ongoing and focused monitoring, contingency planning, and contact information of knowledgeable providers in case questions arise after discharge.2830

Postdischarge care was emphasized with the need for a follow‐up appointment within at most 2 weeks of discharge or sooner for patients with fragile clinical conditions.31 Although this was not recommended because of a published study, it was the consensus of the expert panel and peer review process that close follow‐up after hospital discharge was critical in ensuring medication safety. Transportation limitations and other logistical problems with access to a follow‐up clinician were identified as important issues to be resolved in the discharge planning process in order for timely follow‐up to occur. In addition, it was deemed critical that the follow‐up provider receive the key information about the hospitalization with any necessary follow‐up instructions as soon after discharge as possible13 and certainly before the first postdischarge visit. Instructions to patients about medication schedules and follow‐up care need to be in writing at a 6th‐grade reading level; furthermore, processes to identify a patient's level of understanding of the follow‐up plan and areas for targeted education need to be established.24

DISCUSSION

We believe the development of a checklist of required elements to be communicated at discharge is a key step toward standardizing the hospital discharge process. The checklist highlights what is believed to be the key information about the transition of care and its process. The checklist is intended to standardize what is required for a successful hospital discharge. However, each institution will need to further refine this list according to local factors such as patient population, resources, and culture and to determine how best to implement the necessary changes to their current discharge process. Local modification of the checklist also allows for the addition of other elements that are patient‐ or population specific. Elderly patients discharged home from the hospital are the primary patient population targeted by this checklist ; there may be unique and additional elements necessary for an ideal discharge for a patient who is discharged to a subacute or acute rehabilitation facility. These elements are not described in this checklist but will be the focus of future work.

Establishing the critical elements of a hospital discharge transition sets the stage for improving patient outcomes in the immediate postdischarge period. Most important, the checklist conveys the message that the discharge process requires critical thinking, collaboration, and goal setting and that this coordination of care takes time. However, the discharge checklist must reside within a hospital culture that in general does not value the discharge process in the same way it values the admission process. The latter is more standardized and incorporates expectations about content and communication. In the same way, the current discharge is an admission to the next health care setting and deserves at least as much time and effort as a hospital admission. Furthermore, if institutions examine their current discharge processes, they may find that the time necessary to complete the discharge may be similar to the time necessary to admit a patient to the hospital. Finally, organizations need to develop internal policies and procedures that monitor and provide feedback about important dimensions of the discharge process, including content, patient understanding, information transfer, and clinical and service outcomes including satisfaction of the patient and the postdischarge provider. Hospital discharge is truly a team process involving nurses, pharmacists, case managers, and other hospital personnel, so performance measurement should be at the team or unit level, unlike other areas for which individual physicians may receive feedback on performance.

The limitations of the checklist development process include the paucity of randomized, controlled trials focused on the study of health care delivery processes and the lack of an industry gold standard. Furthermore, the heterogeneity of health care delivery systems makes it difficult to recommend specific interventions without understanding the myriad local issues. Those who provided input into this checklist included members of the inpatient team, a scope that can be broadened in the future to include outpatient physicians, patients, and caregivers in the home and long‐term care environments. However, the elements defined through the checklist serve as a starting point for developing discharge transition standards for older adults.

As leaders in hospital care, hospitalists are positioned to raise awareness of the importance of hospital discharge and to lead multidisciplinary efforts to improve the discharge process within their organizations. The first step in that process should be understanding the required elements and local facilitating factors and barriers in achieving a predictable, seamless transition of care for hospitalized patients.

Hospital discharge is a critical transition point for many inpatients. Patient recovery from diseases requiring hospitalization is frequently incomplete and requires ongoing management and evaluation after discharge. For hospitalists who focus their practice primarily on inpatient care, the handoff to the outpatient setting frequently involves a change in health care provider and care team. Changes in care environment and care goals can lead to adverse patient‐ and system‐level events.1 High‐risk patients with multiple medical issues and elderly patients are especially vulnerable to the consequences of ineffective discharge handoffs.2, 3

Several studies have identified the errors that commonly occur around the time of hospital discharge. Forster et al.4 found that 1 in 5 patients experiences an adverse event (defined as an injury resulting from medical management rather than from the underlying disease) in the transition from hospital to home. They also found that approximately 62% of adverse events could be either prevented or ameliorated.4 Roy et al. examined test results pending at the time of discharge and determined that posthospital providers were frequently unaware of pending test results, with a potentially serious clinical impact.5 In an analysis of adverse events at 2 large hospitals in the United Kingdom, Neale et al. found that almost 11% of those hospitalized had an adverse event, 18% of which were attributable to the discharge process.6

Communication of important transitional care issues to the posthospital care team and to the patient is essential to a safe transition. Studies by van Walraven et al. found that patient follow‐up with a physician who had access to the hospital discharge summary was associated with a decreased risk of rehospitalization.7 Patients not understanding discharge medications,8 dietary restrictions, or other lifestyle changes such as smoking cessation and exercise can lead to ineffective care transitions. Furthermore, the health system's barriers to effective patient self‐management may exacerbate the risk in the transition from the hospital setting.2, 913

In addition to the growing research literature that has identified gaps in the discharge process, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has included discharge instructions as a core performance measure in the care of heart failure patients. Hospital performance on this measure is reported publicly on the Centers for Medicare and Medicaid Services website (www.hospitalcompare.hhs.gov). Furthermore, the 2006 JCAHO patient safety goal of medication reconciliation recognizes the importance of preventing lapses in medication safety at points of care transition.14, 15 JCAHO now requires the development and implementation of processes to collect, review, reconcile, and document prescribed medications at all points of care transition, including hospital discharge.16

Older adults are considered more vulnerable to adverse events after discharge.8 They account for approximately 12% of the total U.S. population, but they make up 70% of hospitalized patients.17 With these factors in mind, the Society of Hospital Medicine (SHM) identified the elderly as a group especially vulnerable to the clinical care handoffs that occur in the hospital discharge process and therefore the patient population targeted in constructing the required elements of an ideal hospital discharge.

In addition to identifying a target patient population, inclusion of stakeholders primarily responsible for implementation is critical to developing a new process standard. In this instance, the hospitalist was identified as a critical architect of the development of the ideal discharge process, although clearly the hospitalist is just one of many people ultimately responsible for coordinating an effective hospital discharge. Finally, the organizations within which the elderly receive care and at which hospitalists practice are important partners in the implementation of systems of care that facilitate seamless care transitions.

In examining the myriad stakeholders involved in the discharge transitionthe patient, the hospitalist, other caregivers involved in hospital care, and the organizationSHM's Hospital Quality & Patient Safety (HQPS) Committee undertook an initiative to develop a practical list of important elements for hospitalists to include in the discharge of elderly inpatients, referred to in this article as the discharge checklist.

METHODS

In a process similar to that used by professional societies in the development of clinical guidelines, the SHM HQPS Committee used a combination of evidence‐based review and expert panels to develop a discharge checklist for elderly patients. Given that the focus of this project was a process improvement rather than a specific clinical condition, the SHM also believed it was critical to share the draft checklist with academic and community‐based practitioners knowledgeable in both the myriad logistical issues of and potential barriers to improving the discharge transition. The detailed process for checklist development is outlined below and summarized in Figure 1.

Figure 1

RESULTS

The final discharge checklist is shown in Figure 2. It contains required and optional data elements and processes for 3 types of discharge documents: the discharge summary, patient instructions, and communication (by phone, e‐mail, or fax) on the day of discharge to the receiving provider. Other documents, such as transfer orders for a rehabilitation facility or nursing home, were considered outside the scope of this project.

Figure 2

The literature review identified medications as a significant source of adverse events for patients upon hospital discharge.4, 8, 14, 1820 The expert panel and workshop participants all endorsed the need for additional detailed attention to reviewing and reconciling medications during the discharge process. The use of standardized tools was suggested by the group to improve the medication review process.21 The required elements include not only a list of discharge medications but also attention to high‐risk medications that require closer postdischarge follow‐up and monitoring (such as warfarin,22 diuretics, nephrotoxic medications, corticosteroids, hypoglycemic medications, and narcotic analgesics), reconciliation of the discharge medication regimen with preadmission medications and designation of medications as new, modified, or discontinued,23 and emphasis on assessing patient understanding of medication self‐management plans.24 Several published studies found that pharmacist oversight of discharge medications or postdischarge telephone calls improved patient outcomes.1820 However, not every health system has the resources and infrastructure necessary to implement these types of programs. Moreover, methods of implementation of each of these discharge elements were believed to be beyond the scope of this project, so pharmacist involvement was not specifically included in this checklist.

The expert panel and workshop participants found items related to cognition and functional status to be important for patients whose usual cognitive or functional status was changed or whose status at discharge was not within normal limits.25, 26 Clinicians seeing patients in follow‐up would then have an important reference point for evaluating progress and the need for additional home support or therapy. Patients with limited literacy or language barriers may need these issues assessed with the help of family members and/or translators to identify changes from their baseline level of functioning.

In addition, resuscitation status was viewed by the group as an important data element for some patients,27 particularly those who had been critically ill. Development of disease or population‐specific content, for example, for patients with heart failure or pneumonia, was also identified as critical to the safe discharge of elderly patient, with the understanding that there may be a need to modify and individualize the content for patients with complex conditions and multiple comorbidities.

The content of the hospital discharge summary deemphasized the need for a complete history of the present illness at the time of hospital admission or an exhaustive hospital course. Instead, it highlighted the need to identify a patient's condition at discharge, pending issues and interventions requiring ongoing and focused monitoring, contingency planning, and contact information of knowledgeable providers in case questions arise after discharge.2830

Postdischarge care was emphasized with the need for a follow‐up appointment within at most 2 weeks of discharge or sooner for patients with fragile clinical conditions.31 Although this was not recommended because of a published study, it was the consensus of the expert panel and peer review process that close follow‐up after hospital discharge was critical in ensuring medication safety. Transportation limitations and other logistical problems with access to a follow‐up clinician were identified as important issues to be resolved in the discharge planning process in order for timely follow‐up to occur. In addition, it was deemed critical that the follow‐up provider receive the key information about the hospitalization with any necessary follow‐up instructions as soon after discharge as possible13 and certainly before the first postdischarge visit. Instructions to patients about medication schedules and follow‐up care need to be in writing at a 6th‐grade reading level; furthermore, processes to identify a patient's level of understanding of the follow‐up plan and areas for targeted education need to be established.24

DISCUSSION

We believe the development of a checklist of required elements to be communicated at discharge is a key step toward standardizing the hospital discharge process. The checklist highlights what is believed to be the key information about the transition of care and its process. The checklist is intended to standardize what is required for a successful hospital discharge. However, each institution will need to further refine this list according to local factors such as patient population, resources, and culture and to determine how best to implement the necessary changes to their current discharge process. Local modification of the checklist also allows for the addition of other elements that are patient‐ or population specific. Elderly patients discharged home from the hospital are the primary patient population targeted by this checklist ; there may be unique and additional elements necessary for an ideal discharge for a patient who is discharged to a subacute or acute rehabilitation facility. These elements are not described in this checklist but will be the focus of future work.

Establishing the critical elements of a hospital discharge transition sets the stage for improving patient outcomes in the immediate postdischarge period. Most important, the checklist conveys the message that the discharge process requires critical thinking, collaboration, and goal setting and that this coordination of care takes time. However, the discharge checklist must reside within a hospital culture that in general does not value the discharge process in the same way it values the admission process. The latter is more standardized and incorporates expectations about content and communication. In the same way, the current discharge is an admission to the next health care setting and deserves at least as much time and effort as a hospital admission. Furthermore, if institutions examine their current discharge processes, they may find that the time necessary to complete the discharge may be similar to the time necessary to admit a patient to the hospital. Finally, organizations need to develop internal policies and procedures that monitor and provide feedback about important dimensions of the discharge process, including content, patient understanding, information transfer, and clinical and service outcomes including satisfaction of the patient and the postdischarge provider. Hospital discharge is truly a team process involving nurses, pharmacists, case managers, and other hospital personnel, so performance measurement should be at the team or unit level, unlike other areas for which individual physicians may receive feedback on performance.

The limitations of the checklist development process include the paucity of randomized, controlled trials focused on the study of health care delivery processes and the lack of an industry gold standard. Furthermore, the heterogeneity of health care delivery systems makes it difficult to recommend specific interventions without understanding the myriad local issues. Those who provided input into this checklist included members of the inpatient team, a scope that can be broadened in the future to include outpatient physicians, patients, and caregivers in the home and long‐term care environments. However, the elements defined through the checklist serve as a starting point for developing discharge transition standards for older adults.

As leaders in hospital care, hospitalists are positioned to raise awareness of the importance of hospital discharge and to lead multidisciplinary efforts to improve the discharge process within their organizations. The first step in that process should be understanding the required elements and local facilitating factors and barriers in achieving a predictable, seamless transition of care for hospitalized patients.

Hospital discharge is a critical transition point for many inpatients. Patient recovery from diseases requiring hospitalization is frequently incomplete and requires ongoing management and evaluation after discharge. For hospitalists who focus their practice primarily on inpatient care, the handoff to the outpatient setting frequently involves a change in health care provider and care team. Changes in care environment and care goals can lead to adverse patient‐ and system‐level events.1 High‐risk patients with multiple medical issues and elderly patients are especially vulnerable to the consequences of ineffective discharge handoffs.2, 3

Several studies have identified the errors that commonly occur around the time of hospital discharge. Forster et al.4 found that 1 in 5 patients experiences an adverse event (defined as an injury resulting from medical management rather than from the underlying disease) in the transition from hospital to home. They also found that approximately 62% of adverse events could be either prevented or ameliorated.4 Roy et al. examined test results pending at the time of discharge and determined that posthospital providers were frequently unaware of pending test results, with a potentially serious clinical impact.5 In an analysis of adverse events at 2 large hospitals in the United Kingdom, Neale et al. found that almost 11% of those hospitalized had an adverse event, 18% of which were attributable to the discharge process.6

Communication of important transitional care issues to the posthospital care team and to the patient is essential to a safe transition. Studies by van Walraven et al. found that patient follow‐up with a physician who had access to the hospital discharge summary was associated with a decreased risk of rehospitalization.7 Patients not understanding discharge medications,8 dietary restrictions, or other lifestyle changes such as smoking cessation and exercise can lead to ineffective care transitions. Furthermore, the health system's barriers to effective patient self‐management may exacerbate the risk in the transition from the hospital setting.2, 913

In addition to the growing research literature that has identified gaps in the discharge process, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has included discharge instructions as a core performance measure in the care of heart failure patients. Hospital performance on this measure is reported publicly on the Centers for Medicare and Medicaid Services website (www.hospitalcompare.hhs.gov). Furthermore, the 2006 JCAHO patient safety goal of medication reconciliation recognizes the importance of preventing lapses in medication safety at points of care transition.14, 15 JCAHO now requires the development and implementation of processes to collect, review, reconcile, and document prescribed medications at all points of care transition, including hospital discharge.16

Older adults are considered more vulnerable to adverse events after discharge.8 They account for approximately 12% of the total U.S. population, but they make up 70% of hospitalized patients.17 With these factors in mind, the Society of Hospital Medicine (SHM) identified the elderly as a group especially vulnerable to the clinical care handoffs that occur in the hospital discharge process and therefore the patient population targeted in constructing the required elements of an ideal hospital discharge.

In addition to identifying a target patient population, inclusion of stakeholders primarily responsible for implementation is critical to developing a new process standard. In this instance, the hospitalist was identified as a critical architect of the development of the ideal discharge process, although clearly the hospitalist is just one of many people ultimately responsible for coordinating an effective hospital discharge. Finally, the organizations within which the elderly receive care and at which hospitalists practice are important partners in the implementation of systems of care that facilitate seamless care transitions.

In examining the myriad stakeholders involved in the discharge transitionthe patient, the hospitalist, other caregivers involved in hospital care, and the organizationSHM's Hospital Quality & Patient Safety (HQPS) Committee undertook an initiative to develop a practical list of important elements for hospitalists to include in the discharge of elderly inpatients, referred to in this article as the discharge checklist.

METHODS

In a process similar to that used by professional societies in the development of clinical guidelines, the SHM HQPS Committee used a combination of evidence‐based review and expert panels to develop a discharge checklist for elderly patients. Given that the focus of this project was a process improvement rather than a specific clinical condition, the SHM also believed it was critical to share the draft checklist with academic and community‐based practitioners knowledgeable in both the myriad logistical issues of and potential barriers to improving the discharge transition. The detailed process for checklist development is outlined below and summarized in Figure 1.

Figure 1

RESULTS

The final discharge checklist is shown in Figure 2. It contains required and optional data elements and processes for 3 types of discharge documents: the discharge summary, patient instructions, and communication (by phone, e‐mail, or fax) on the day of discharge to the receiving provider. Other documents, such as transfer orders for a rehabilitation facility or nursing home, were considered outside the scope of this project.

Figure 2

The literature review identified medications as a significant source of adverse events for patients upon hospital discharge.4, 8, 14, 1820 The expert panel and workshop participants all endorsed the need for additional detailed attention to reviewing and reconciling medications during the discharge process. The use of standardized tools was suggested by the group to improve the medication review process.21 The required elements include not only a list of discharge medications but also attention to high‐risk medications that require closer postdischarge follow‐up and monitoring (such as warfarin,22 diuretics, nephrotoxic medications, corticosteroids, hypoglycemic medications, and narcotic analgesics), reconciliation of the discharge medication regimen with preadmission medications and designation of medications as new, modified, or discontinued,23 and emphasis on assessing patient understanding of medication self‐management plans.24 Several published studies found that pharmacist oversight of discharge medications or postdischarge telephone calls improved patient outcomes.1820 However, not every health system has the resources and infrastructure necessary to implement these types of programs. Moreover, methods of implementation of each of these discharge elements were believed to be beyond the scope of this project, so pharmacist involvement was not specifically included in this checklist.

The expert panel and workshop participants found items related to cognition and functional status to be important for patients whose usual cognitive or functional status was changed or whose status at discharge was not within normal limits.25, 26 Clinicians seeing patients in follow‐up would then have an important reference point for evaluating progress and the need for additional home support or therapy. Patients with limited literacy or language barriers may need these issues assessed with the help of family members and/or translators to identify changes from their baseline level of functioning.

In addition, resuscitation status was viewed by the group as an important data element for some patients,27 particularly those who had been critically ill. Development of disease or population‐specific content, for example, for patients with heart failure or pneumonia, was also identified as critical to the safe discharge of elderly patient, with the understanding that there may be a need to modify and individualize the content for patients with complex conditions and multiple comorbidities.

The content of the hospital discharge summary deemphasized the need for a complete history of the present illness at the time of hospital admission or an exhaustive hospital course. Instead, it highlighted the need to identify a patient's condition at discharge, pending issues and interventions requiring ongoing and focused monitoring, contingency planning, and contact information of knowledgeable providers in case questions arise after discharge.2830

Postdischarge care was emphasized with the need for a follow‐up appointment within at most 2 weeks of discharge or sooner for patients with fragile clinical conditions.31 Although this was not recommended because of a published study, it was the consensus of the expert panel and peer review process that close follow‐up after hospital discharge was critical in ensuring medication safety. Transportation limitations and other logistical problems with access to a follow‐up clinician were identified as important issues to be resolved in the discharge planning process in order for timely follow‐up to occur. In addition, it was deemed critical that the follow‐up provider receive the key information about the hospitalization with any necessary follow‐up instructions as soon after discharge as possible13 and certainly before the first postdischarge visit. Instructions to patients about medication schedules and follow‐up care need to be in writing at a 6th‐grade reading level; furthermore, processes to identify a patient's level of understanding of the follow‐up plan and areas for targeted education need to be established.24

DISCUSSION

We believe the development of a checklist of required elements to be communicated at discharge is a key step toward standardizing the hospital discharge process. The checklist highlights what is believed to be the key information about the transition of care and its process. The checklist is intended to standardize what is required for a successful hospital discharge. However, each institution will need to further refine this list according to local factors such as patient population, resources, and culture and to determine how best to implement the necessary changes to their current discharge process. Local modification of the checklist also allows for the addition of other elements that are patient‐ or population specific. Elderly patients discharged home from the hospital are the primary patient population targeted by this checklist ; there may be unique and additional elements necessary for an ideal discharge for a patient who is discharged to a subacute or acute rehabilitation facility. These elements are not described in this checklist but will be the focus of future work.

Establishing the critical elements of a hospital discharge transition sets the stage for improving patient outcomes in the immediate postdischarge period. Most important, the checklist conveys the message that the discharge process requires critical thinking, collaboration, and goal setting and that this coordination of care takes time. However, the discharge checklist must reside within a hospital culture that in general does not value the discharge process in the same way it values the admission process. The latter is more standardized and incorporates expectations about content and communication. In the same way, the current discharge is an admission to the next health care setting and deserves at least as much time and effort as a hospital admission. Furthermore, if institutions examine their current discharge processes, they may find that the time necessary to complete the discharge may be similar to the time necessary to admit a patient to the hospital. Finally, organizations need to develop internal policies and procedures that monitor and provide feedback about important dimensions of the discharge process, including content, patient understanding, information transfer, and clinical and service outcomes including satisfaction of the patient and the postdischarge provider. Hospital discharge is truly a team process involving nurses, pharmacists, case managers, and other hospital personnel, so performance measurement should be at the team or unit level, unlike other areas for which individual physicians may receive feedback on performance.

The limitations of the checklist development process include the paucity of randomized, controlled trials focused on the study of health care delivery processes and the lack of an industry gold standard. Furthermore, the heterogeneity of health care delivery systems makes it difficult to recommend specific interventions without understanding the myriad local issues. Those who provided input into this checklist included members of the inpatient team, a scope that can be broadened in the future to include outpatient physicians, patients, and caregivers in the home and long‐term care environments. However, the elements defined through the checklist serve as a starting point for developing discharge transition standards for older adults.

As leaders in hospital care, hospitalists are positioned to raise awareness of the importance of hospital discharge and to lead multidisciplinary efforts to improve the discharge process within their organizations. The first step in that process should be understanding the required elements and local facilitating factors and barriers in achieving a predictable, seamless transition of care for hospitalized patients.

• CLINICAL QUESTION: In patients hospitalized for treatment of community‐acquired pneumonia, can treatment be stopped after 3 days if the patient has substantially improved?

• BOTTOM LINE: Dogma successfully challenged: In patients who respond well to initial treatment, stopping antibiotic therapy after 3 days is just as effective as continuing treatment for the standard 8 days. (LOE = 1b)

• REFERENCE: el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderatesevere community acquired pneumonia: randomised, double blind study. BMJ 2006;332:13551358.

• STUDY DESIGN: Randomized controlled trial (doubleblinded)

• FUNDING: Industry

• ALLOCATION: Uncertain

• SETTING: Inpatient (any location)

• SYNOPSIS: The treatment of pneumonia for 7 days to 10 days is based on tradition, not scientific evidence. The researchers conducting this study challenged the status quo by enrolling 119 adults with mild to moderatesevere communityacquired pneumonia with a severity index score of 110 or less. On admission, all patients were started on intravenous amoxicillin, the preferred empirical treatment in the Netherlands. After 72 hours of treatment, patients who showed improvement in symptoms, had a temperature of less than 38 C, and could take oral drugs were randomized to treatment with placebo or amoxicillin 750 mg 3 times daily for 5 days. Using modified intentiontotreat analysis, after 10 days 89% of patients in both groups were clinically cured. In followup at 28 days, clinical cure rates were also similar between the 2 approaches, as was bacteriologic success and radiologic success. This study was designed to find a difference in success rates of at least 10%. There are a couple of notable limitations to this study. First, the patients in the shorttreatment group had a median age of 54 years compared with 60 years in the 8day group, and these younger patients may be more likely to respond to the short course, thus skewing the results. Second, the study was conducted in the Netherlands, where resistance patterns may be different than in other countries. Finally, the study was conducted in 9 hospitals over 3 years, which works out to less than 5 patients per hospital per year recruited into the study. Given the imbalance in age and this sparse representation, these patients could be highly selected and not representative of the typical patient admitted to a community hospital.

• CLINICAL QUESTION: In patients hospitalized for treatment of community‐acquired pneumonia, can treatment be stopped after 3 days if the patient has substantially improved?

• BOTTOM LINE: Dogma successfully challenged: In patients who respond well to initial treatment, stopping antibiotic therapy after 3 days is just as effective as continuing treatment for the standard 8 days. (LOE = 1b)

• REFERENCE: el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderatesevere community acquired pneumonia: randomised, double blind study. BMJ 2006;332:13551358.

• STUDY DESIGN: Randomized controlled trial (doubleblinded)

• FUNDING: Industry

• ALLOCATION: Uncertain

• SETTING: Inpatient (any location)

• SYNOPSIS: The treatment of pneumonia for 7 days to 10 days is based on tradition, not scientific evidence. The researchers conducting this study challenged the status quo by enrolling 119 adults with mild to moderatesevere communityacquired pneumonia with a severity index score of 110 or less. On admission, all patients were started on intravenous amoxicillin, the preferred empirical treatment in the Netherlands. After 72 hours of treatment, patients who showed improvement in symptoms, had a temperature of less than 38 C, and could take oral drugs were randomized to treatment with placebo or amoxicillin 750 mg 3 times daily for 5 days. Using modified intentiontotreat analysis, after 10 days 89% of patients in both groups were clinically cured. In followup at 28 days, clinical cure rates were also similar between the 2 approaches, as was bacteriologic success and radiologic success. This study was designed to find a difference in success rates of at least 10%. There are a couple of notable limitations to this study. First, the patients in the shorttreatment group had a median age of 54 years compared with 60 years in the 8day group, and these younger patients may be more likely to respond to the short course, thus skewing the results. Second, the study was conducted in the Netherlands, where resistance patterns may be different than in other countries. Finally, the study was conducted in 9 hospitals over 3 years, which works out to less than 5 patients per hospital per year recruited into the study. Given the imbalance in age and this sparse representation, these patients could be highly selected and not representative of the typical patient admitted to a community hospital.

• CLINICAL QUESTION: In patients hospitalized for treatment of community‐acquired pneumonia, can treatment be stopped after 3 days if the patient has substantially improved?

• BOTTOM LINE: Dogma successfully challenged: In patients who respond well to initial treatment, stopping antibiotic therapy after 3 days is just as effective as continuing treatment for the standard 8 days. (LOE = 1b)

• REFERENCE: el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderatesevere community acquired pneumonia: randomised, double blind study. BMJ 2006;332:13551358.

• STUDY DESIGN: Randomized controlled trial (doubleblinded)

• FUNDING: Industry

• ALLOCATION: Uncertain

• SETTING: Inpatient (any location)

• SYNOPSIS: The treatment of pneumonia for 7 days to 10 days is based on tradition, not scientific evidence. The researchers conducting this study challenged the status quo by enrolling 119 adults with mild to moderatesevere communityacquired pneumonia with a severity index score of 110 or less. On admission, all patients were started on intravenous amoxicillin, the preferred empirical treatment in the Netherlands. After 72 hours of treatment, patients who showed improvement in symptoms, had a temperature of less than 38 C, and could take oral drugs were randomized to treatment with placebo or amoxicillin 750 mg 3 times daily for 5 days. Using modified intentiontotreat analysis, after 10 days 89% of patients in both groups were clinically cured. In followup at 28 days, clinical cure rates were also similar between the 2 approaches, as was bacteriologic success and radiologic success. This study was designed to find a difference in success rates of at least 10%. There are a couple of notable limitations to this study. First, the patients in the shorttreatment group had a median age of 54 years compared with 60 years in the 8day group, and these younger patients may be more likely to respond to the short course, thus skewing the results. Second, the study was conducted in the Netherlands, where resistance patterns may be different than in other countries. Finally, the study was conducted in 9 hospitals over 3 years, which works out to less than 5 patients per hospital per year recruited into the study. Given the imbalance in age and this sparse representation, these patients could be highly selected and not representative of the typical patient admitted to a community hospital.

Venous thromboembolism (VTE), which encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of the morbidity and mortality of hospitalized medical patients.1 Hospitalization for an acute medical illness has been associated with an 8‐fold increase in the relative risk of VTE and is responsible for approximately a quarter of all VTE cases in the general population.2, 3

Current evidence‐based guidelines, including those from the American College of Chest Physicians (ACCP), recommend prophylaxis with low‐dose unfractionated heparin (UFH) or low‐molecular‐weight heparin (LMWH) for medical patients with risk factors for VTE.4, 5 Mechanical prophylaxis methods including graduated compression stockings and intermittent pneumatic compression are recommended for those patients for whom anticoagulant therapy is contraindicated because of a high risk of bleeding.4, 5 However, several studies have shown that adherence to these guidelines is suboptimal, with many at‐risk patients receiving inadequate prophylaxis (range 32%‐87%).610

Physician‐related factors identified as potential barriers to guideline adherence include not being aware or familiar with the guidelines, not agreeing with the guidelines, or believing the guideline recommendations to be ineffective.11 More specific studies have shown that some physicians may lack basic knowledge regarding the current treatment standards for VTE and may underestimate the significance of VTE.1213 As distinct strategies, education aimed at disseminating VTE prophylaxis guidelines, as well as regular audit‐and‐feedback of physician performance, has been shown to improve rates of VTE prophylaxis in clinical practice.6, 1417 Implementation of educational programs significantly increased the level of appropriate VTE prophylaxis from 59% to 70% of patients in an Australian hospital15 and from 73% to 97% of patients in a Scottish hospital.14 Another strategy, the use of point‐of‐care electronically provided reminders with decision support, has been successful not only in increasing the rates of VTE prophylaxis, but also in decreasing the incidence of clinical VTE events.16 Although highly effective, electronic alerts with computerized decision support do not exist in many hospitals, and other methods of intervention are needed.

In this study, we evaluated adherence to the 2001 ACCP guidelines for VTE prophylaxis among medical patients in our teaching hospital. (The guidelines were updated in 2004, after our study was completed.) After determining that our baseline rates of appropriate VTE prophylaxis were suboptimal, we developed, implemented, and evaluated a multifaceted strategy to improve the rates of appropriate thromboprophylaxis among our medical inpatients.

Six categories of quality improvement strategies have been described: provider education, decision support, audit‐and‐feedback, patient education, organization change, and regulation and policy.18 The intervention we developed was a composite of 3 of these: provider education, decision support, and audit‐and‐feedback.

METHODS

RESULTS

Risk Factors for VTE

Patient risk factors for VTE in each data collection period are summarized in Table 4. Analysis of this data showed that the most prevalent risk factors for VTE in the 3 patient populations were age older than 40 years (262/312, 84.0% of the total patient population) and nonambulatory state (231/271, 85.2% of the total population). Overall, the average number of risk factors for VTE was approximately 3, with more than 60% of patients having 3 or more VTE risk factors (Fig. 1).

Figure 1

Change in Prophylaxis Use

Twelve and 18 months after implementation of the quality improvement program, we observed an increase in the use of any prophylaxis, from 46.9% at baseline to 86.2% and 86.4%, respectively (Table 5; P < .01 in both groups versus baseline). This increase was a result almost entirely of an increase in the proportion of patients receiving pharmacological prophylaxis, which significantly increased, from 44.9% to 81.0% and 80.3%, at the 12‐ and 18‐month time points, respectively (Table 5; P < .01 for both groups versus baseline). Most meaningfully, there was a significant increase in the proportion of patients for whom an appropriate prophylaxis decision was made (from 42.9% to 68.1% and 85.0%, at the 12‐ and 18‐month time points, respectively; Table 6; P < .01 for both groups versus baseline). This represented a trend toward continuing increases in the use of appropriate prophylaxis as the study progressed (Fig. 2). This change was driven mainly by a significant increase in the prescribing of LMWH, almost all of which was prescribed in accordance with the 2001 ACCP guidelines (Table 6).

Figure 2

DISCUSSION

In this study we evaluated the effect of an intervention that combined physician education with a decision support tool and a mechanism for audit‐and‐feedback. We have shown that implementation of such a multifaceted intervention is practical in a teaching hospital and can improve the rates of VTE prophylaxis use in medical patients. In nearly doubling the rate of appropriate prophylaxis, the effect size of our intervention was large, statistically significant, and sustained 18 months after implementation.

More than 60% of our patients had 3 or more risk factors, and more than 80% had at least 2 risk factors. The rate we observed for patients with 3 or more risk factors was 3 times higher than that reported previously.22 Despite the prevalence of high‐risk patients in our study, we observed that the preintervention rate of VTE prophylaxis among medical patients was relatively low at 47%, and only 43% of patients received prophylaxis in accordance with the ACCP guidelines. Our study findings are consistent with those of several other studies that have shown low rates of VTE prophylaxis in medical patients.6, 8, 2324 In a study of 15 hospitals in Massachusetts, only 13%‐19% of medical patients with indications and risk factors for VTE prophylaxis received any prophylaxis prior to an educational intervention.6 Similarly, a study of 368 consecutive medical patients at a Swiss hospital showed that only 22% of those at‐risk received VTE prophylaxis in accordance with the Thromboembolic Risk Factors (THRIFT) I Consensus Group recommendations.8 Results from 2 prospective patient registries also indicated low rates of VTE prophylaxis in medical patients.19, 24 In the IMPROVE registry of acutely ill medical patients, only 39% of patients hospitalized for 3 or more days received VTE prophylaxis19 and in the DVT‐FREE registry only 42% of medical patients with the inpatient diagnosis of DVT had received prophylaxis within 30 days of that diagnosis.24 In a recent retrospective study of 217 medical patients at the University of Utah hospital, just 43% of patients at high risk for VTE received any sort of prophylaxis.23

Physician education was the main intervention in several previous studies aimed at raising rates of VTE prophylaxis. Our study joins those that have also shown significant improvements after implementation of VTE prophylaxis educational initiatives.6, 14, 15, 23 In the study by Anderson et al., a significantly greater increase in the proportion of high‐risk patients receiving effective VTE prophylaxis was seen between 1986 and 1989 in hospitals that participated in a formal continuing medical education program compared with those that did not (increase: 28% versus 11%; P < .001).6 In 3 additional studies, educational interventions were shown to increase the rate of appropriate prophylaxis in at‐risk patients from 59% to 70%, from 55% to 96%, and from 43% to 72%.14, 15, 23

Other studies have cast doubt on the ability of time‐limited educational interventions to achieve a large or sustained effect.27, 28 A recent systematic review of strategies to improve the use of prophylaxis in hospitals concluded that a number of active strategies are likely to achieve optimal outcomes by combining a system for reminding clinicians to assess patients for VTE with assisting the selection of prophylaxis and providing audit‐and‐feedback.29 The large, sustained effect reported in our study might have been a result of the multifaceted and ongoing nature of the intervention, with reintroduction of the material to all incoming house staff each month. An audit from the last quarter of 2005nearly 2 years after the start of our interventionshowed that prophylaxis rates were approaching 100% (data not included in this study).

Another strategy, the use of computerized reminders to physicians, has been shown to increase the rate of VTE prophylaxis in surgical and medical/surgical patients.16, 26 Kucher et al. compared the incidence of DVT or PE in 1255 hospitalized patients whose physicians received an electronic alert of patient risk of DVT with 1251 hospitalized patients whose physicians did not receive such an alert. They found that the computer alert was associated with a significant reduction in the incidence of DVT or PE at 90 days, with a hazard ratio of 0.59 (95% confidence interval: 0.43, 0.81).16 Our study offers one practical alternative for those institutions that, like ours, do not currently have computerized order entry.

We were unable to determine if there was a specific element of the multifaceted VTE prophylaxis intervention program that contributed the most to the improvement in prophylaxis rates. Provider education was ongoing rather than just a single educational campaign. It was further supported by the pocket cards that provided support for decision making on VTE risk factors, risk categories (based on number and type of risk factor), recommended prophylaxis choices, and potential contraindications. In addition, our method of audit‐and‐feedback constructively leveraged the Hawthorne effect: aware that individual behavior was being measured, our physicians likely adjusted their practice accordingly. Taken together, it is likely that the several elements of our intervention were more powerful in combination than they would have been alone.

Although the multifaceted intervention worked well within our urban university teaching hospital, its application and outcome might be different for other types of hospitals. In our audit‐and‐feedback, for instance, review of resident physician performance was conducted by the Division Chief of General Internal Medicine, tapping into a very strong authority gradient. Hierarchical structures are likely to be different in other types of hospitals. It would therefore be valuable to examine whether the audit‐and‐feedback methodology presented in this article can be replicated in other hospital settings.

A potential limitation of this study was the use of retrospective review to determine baseline rates of VTE prophylaxis. This approach relies on medical notes being accurate and complete; such notes may not have been available for each patient. However, random reviews of both patient charts and hospital billing data for comorbidities performed after coding as a quality control step allowed for confirmation of the data or the extraction and addition of missing data. In addition, data collection was limited to a single day in the latter half of the month. It is not clear whether this sampling strategy collects data that are reflective of performance for the entire month. Our study was also limited by the absence of a control group. Without a control group, we cannot exclude the possibility that during the study factors other than the educational intervention might have contributed to the improvement in prophylaxis rates.

In this study we did not address whether an increase in VTE prophylaxis use translates to an improvement in patient outcomes, namely, a reduction in the rate of VTE. Mosen et al. showed that increasing the VTE prophylaxis rate by implementing a computerized reminder system did not decrease the rate of VTE.26 However, the baseline rate of VTE prophylaxis was already very good, and the study was only powered to detect a large difference in VTE rates. Conversely, Kucher et al. recently demonstrated a significant reduction in VTE events 90 days after initiation of a computerized alert program.16 Further studies designed to confirm the inverse relationship between rate of VTE prophylaxis and rate of clinical outcome of VTE would be helpful.

In conclusion, in a setting in which most hospitalized medically ill patients have multiple risk factors for VTE, we have shown that a practical multifaceted intervention can result in a marked increase in the proportion of medical patients receiving VTE prophylaxis, as well as in the proportion of patients receiving prophylaxis commensurate with evidence‐based guidelines.

Venous thromboembolism (VTE), which encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of the morbidity and mortality of hospitalized medical patients.1 Hospitalization for an acute medical illness has been associated with an 8‐fold increase in the relative risk of VTE and is responsible for approximately a quarter of all VTE cases in the general population.2, 3

Current evidence‐based guidelines, including those from the American College of Chest Physicians (ACCP), recommend prophylaxis with low‐dose unfractionated heparin (UFH) or low‐molecular‐weight heparin (LMWH) for medical patients with risk factors for VTE.4, 5 Mechanical prophylaxis methods including graduated compression stockings and intermittent pneumatic compression are recommended for those patients for whom anticoagulant therapy is contraindicated because of a high risk of bleeding.4, 5 However, several studies have shown that adherence to these guidelines is suboptimal, with many at‐risk patients receiving inadequate prophylaxis (range 32%‐87%).610

Physician‐related factors identified as potential barriers to guideline adherence include not being aware or familiar with the guidelines, not agreeing with the guidelines, or believing the guideline recommendations to be ineffective.11 More specific studies have shown that some physicians may lack basic knowledge regarding the current treatment standards for VTE and may underestimate the significance of VTE.1213 As distinct strategies, education aimed at disseminating VTE prophylaxis guidelines, as well as regular audit‐and‐feedback of physician performance, has been shown to improve rates of VTE prophylaxis in clinical practice.6, 1417 Implementation of educational programs significantly increased the level of appropriate VTE prophylaxis from 59% to 70% of patients in an Australian hospital15 and from 73% to 97% of patients in a Scottish hospital.14 Another strategy, the use of point‐of‐care electronically provided reminders with decision support, has been successful not only in increasing the rates of VTE prophylaxis, but also in decreasing the incidence of clinical VTE events.16 Although highly effective, electronic alerts with computerized decision support do not exist in many hospitals, and other methods of intervention are needed.

In this study, we evaluated adherence to the 2001 ACCP guidelines for VTE prophylaxis among medical patients in our teaching hospital. (The guidelines were updated in 2004, after our study was completed.) After determining that our baseline rates of appropriate VTE prophylaxis were suboptimal, we developed, implemented, and evaluated a multifaceted strategy to improve the rates of appropriate thromboprophylaxis among our medical inpatients.

Six categories of quality improvement strategies have been described: provider education, decision support, audit‐and‐feedback, patient education, organization change, and regulation and policy.18 The intervention we developed was a composite of 3 of these: provider education, decision support, and audit‐and‐feedback.

METHODS

RESULTS

Risk Factors for VTE

Patient risk factors for VTE in each data collection period are summarized in Table 4. Analysis of this data showed that the most prevalent risk factors for VTE in the 3 patient populations were age older than 40 years (262/312, 84.0% of the total patient population) and nonambulatory state (231/271, 85.2% of the total population). Overall, the average number of risk factors for VTE was approximately 3, with more than 60% of patients having 3 or more VTE risk factors (Fig. 1).

Figure 1

Change in Prophylaxis Use

Twelve and 18 months after implementation of the quality improvement program, we observed an increase in the use of any prophylaxis, from 46.9% at baseline to 86.2% and 86.4%, respectively (Table 5; P < .01 in both groups versus baseline). This increase was a result almost entirely of an increase in the proportion of patients receiving pharmacological prophylaxis, which significantly increased, from 44.9% to 81.0% and 80.3%, at the 12‐ and 18‐month time points, respectively (Table 5; P < .01 for both groups versus baseline). Most meaningfully, there was a significant increase in the proportion of patients for whom an appropriate prophylaxis decision was made (from 42.9% to 68.1% and 85.0%, at the 12‐ and 18‐month time points, respectively; Table 6; P < .01 for both groups versus baseline). This represented a trend toward continuing increases in the use of appropriate prophylaxis as the study progressed (Fig. 2). This change was driven mainly by a significant increase in the prescribing of LMWH, almost all of which was prescribed in accordance with the 2001 ACCP guidelines (Table 6).

Figure 2

DISCUSSION

In this study we evaluated the effect of an intervention that combined physician education with a decision support tool and a mechanism for audit‐and‐feedback. We have shown that implementation of such a multifaceted intervention is practical in a teaching hospital and can improve the rates of VTE prophylaxis use in medical patients. In nearly doubling the rate of appropriate prophylaxis, the effect size of our intervention was large, statistically significant, and sustained 18 months after implementation.

More than 60% of our patients had 3 or more risk factors, and more than 80% had at least 2 risk factors. The rate we observed for patients with 3 or more risk factors was 3 times higher than that reported previously.22 Despite the prevalence of high‐risk patients in our study, we observed that the preintervention rate of VTE prophylaxis among medical patients was relatively low at 47%, and only 43% of patients received prophylaxis in accordance with the ACCP guidelines. Our study findings are consistent with those of several other studies that have shown low rates of VTE prophylaxis in medical patients.6, 8, 2324 In a study of 15 hospitals in Massachusetts, only 13%‐19% of medical patients with indications and risk factors for VTE prophylaxis received any prophylaxis prior to an educational intervention.6 Similarly, a study of 368 consecutive medical patients at a Swiss hospital showed that only 22% of those at‐risk received VTE prophylaxis in accordance with the Thromboembolic Risk Factors (THRIFT) I Consensus Group recommendations.8 Results from 2 prospective patient registries also indicated low rates of VTE prophylaxis in medical patients.19, 24 In the IMPROVE registry of acutely ill medical patients, only 39% of patients hospitalized for 3 or more days received VTE prophylaxis19 and in the DVT‐FREE registry only 42% of medical patients with the inpatient diagnosis of DVT had received prophylaxis within 30 days of that diagnosis.24 In a recent retrospective study of 217 medical patients at the University of Utah hospital, just 43% of patients at high risk for VTE received any sort of prophylaxis.23

Physician education was the main intervention in several previous studies aimed at raising rates of VTE prophylaxis. Our study joins those that have also shown significant improvements after implementation of VTE prophylaxis educational initiatives.6, 14, 15, 23 In the study by Anderson et al., a significantly greater increase in the proportion of high‐risk patients receiving effective VTE prophylaxis was seen between 1986 and 1989 in hospitals that participated in a formal continuing medical education program compared with those that did not (increase: 28% versus 11%; P < .001).6 In 3 additional studies, educational interventions were shown to increase the rate of appropriate prophylaxis in at‐risk patients from 59% to 70%, from 55% to 96%, and from 43% to 72%.14, 15, 23

Other studies have cast doubt on the ability of time‐limited educational interventions to achieve a large or sustained effect.27, 28 A recent systematic review of strategies to improve the use of prophylaxis in hospitals concluded that a number of active strategies are likely to achieve optimal outcomes by combining a system for reminding clinicians to assess patients for VTE with assisting the selection of prophylaxis and providing audit‐and‐feedback.29 The large, sustained effect reported in our study might have been a result of the multifaceted and ongoing nature of the intervention, with reintroduction of the material to all incoming house staff each month. An audit from the last quarter of 2005nearly 2 years after the start of our interventionshowed that prophylaxis rates were approaching 100% (data not included in this study).

Another strategy, the use of computerized reminders to physicians, has been shown to increase the rate of VTE prophylaxis in surgical and medical/surgical patients.16, 26 Kucher et al. compared the incidence of DVT or PE in 1255 hospitalized patients whose physicians received an electronic alert of patient risk of DVT with 1251 hospitalized patients whose physicians did not receive such an alert. They found that the computer alert was associated with a significant reduction in the incidence of DVT or PE at 90 days, with a hazard ratio of 0.59 (95% confidence interval: 0.43, 0.81).16 Our study offers one practical alternative for those institutions that, like ours, do not currently have computerized order entry.

We were unable to determine if there was a specific element of the multifaceted VTE prophylaxis intervention program that contributed the most to the improvement in prophylaxis rates. Provider education was ongoing rather than just a single educational campaign. It was further supported by the pocket cards that provided support for decision making on VTE risk factors, risk categories (based on number and type of risk factor), recommended prophylaxis choices, and potential contraindications. In addition, our method of audit‐and‐feedback constructively leveraged the Hawthorne effect: aware that individual behavior was being measured, our physicians likely adjusted their practice accordingly. Taken together, it is likely that the several elements of our intervention were more powerful in combination than they would have been alone.

Although the multifaceted intervention worked well within our urban university teaching hospital, its application and outcome might be different for other types of hospitals. In our audit‐and‐feedback, for instance, review of resident physician performance was conducted by the Division Chief of General Internal Medicine, tapping into a very strong authority gradient. Hierarchical structures are likely to be different in other types of hospitals. It would therefore be valuable to examine whether the audit‐and‐feedback methodology presented in this article can be replicated in other hospital settings.

A potential limitation of this study was the use of retrospective review to determine baseline rates of VTE prophylaxis. This approach relies on medical notes being accurate and complete; such notes may not have been available for each patient. However, random reviews of both patient charts and hospital billing data for comorbidities performed after coding as a quality control step allowed for confirmation of the data or the extraction and addition of missing data. In addition, data collection was limited to a single day in the latter half of the month. It is not clear whether this sampling strategy collects data that are reflective of performance for the entire month. Our study was also limited by the absence of a control group. Without a control group, we cannot exclude the possibility that during the study factors other than the educational intervention might have contributed to the improvement in prophylaxis rates.

In this study we did not address whether an increase in VTE prophylaxis use translates to an improvement in patient outcomes, namely, a reduction in the rate of VTE. Mosen et al. showed that increasing the VTE prophylaxis rate by implementing a computerized reminder system did not decrease the rate of VTE.26 However, the baseline rate of VTE prophylaxis was already very good, and the study was only powered to detect a large difference in VTE rates. Conversely, Kucher et al. recently demonstrated a significant reduction in VTE events 90 days after initiation of a computerized alert program.16 Further studies designed to confirm the inverse relationship between rate of VTE prophylaxis and rate of clinical outcome of VTE would be helpful.

In conclusion, in a setting in which most hospitalized medically ill patients have multiple risk factors for VTE, we have shown that a practical multifaceted intervention can result in a marked increase in the proportion of medical patients receiving VTE prophylaxis, as well as in the proportion of patients receiving prophylaxis commensurate with evidence‐based guidelines.

Venous thromboembolism (VTE), which encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of the morbidity and mortality of hospitalized medical patients.1 Hospitalization for an acute medical illness has been associated with an 8‐fold increase in the relative risk of VTE and is responsible for approximately a quarter of all VTE cases in the general population.2, 3

Current evidence‐based guidelines, including those from the American College of Chest Physicians (ACCP), recommend prophylaxis with low‐dose unfractionated heparin (UFH) or low‐molecular‐weight heparin (LMWH) for medical patients with risk factors for VTE.4, 5 Mechanical prophylaxis methods including graduated compression stockings and intermittent pneumatic compression are recommended for those patients for whom anticoagulant therapy is contraindicated because of a high risk of bleeding.4, 5 However, several studies have shown that adherence to these guidelines is suboptimal, with many at‐risk patients receiving inadequate prophylaxis (range 32%‐87%).610

Physician‐related factors identified as potential barriers to guideline adherence include not being aware or familiar with the guidelines, not agreeing with the guidelines, or believing the guideline recommendations to be ineffective.11 More specific studies have shown that some physicians may lack basic knowledge regarding the current treatment standards for VTE and may underestimate the significance of VTE.1213 As distinct strategies, education aimed at disseminating VTE prophylaxis guidelines, as well as regular audit‐and‐feedback of physician performance, has been shown to improve rates of VTE prophylaxis in clinical practice.6, 1417 Implementation of educational programs significantly increased the level of appropriate VTE prophylaxis from 59% to 70% of patients in an Australian hospital15 and from 73% to 97% of patients in a Scottish hospital.14 Another strategy, the use of point‐of‐care electronically provided reminders with decision support, has been successful not only in increasing the rates of VTE prophylaxis, but also in decreasing the incidence of clinical VTE events.16 Although highly effective, electronic alerts with computerized decision support do not exist in many hospitals, and other methods of intervention are needed.

In this study, we evaluated adherence to the 2001 ACCP guidelines for VTE prophylaxis among medical patients in our teaching hospital. (The guidelines were updated in 2004, after our study was completed.) After determining that our baseline rates of appropriate VTE prophylaxis were suboptimal, we developed, implemented, and evaluated a multifaceted strategy to improve the rates of appropriate thromboprophylaxis among our medical inpatients.

Six categories of quality improvement strategies have been described: provider education, decision support, audit‐and‐feedback, patient education, organization change, and regulation and policy.18 The intervention we developed was a composite of 3 of these: provider education, decision support, and audit‐and‐feedback.

METHODS

RESULTS

Risk Factors for VTE

Patient risk factors for VTE in each data collection period are summarized in Table 4. Analysis of this data showed that the most prevalent risk factors for VTE in the 3 patient populations were age older than 40 years (262/312, 84.0% of the total patient population) and nonambulatory state (231/271, 85.2% of the total population). Overall, the average number of risk factors for VTE was approximately 3, with more than 60% of patients having 3 or more VTE risk factors (Fig. 1).

Figure 1